Another thing that is assessed would be your skin. The doctor or nurse could be looking for something like a wound would be a big concern and should cause them to go into a whole different mode of acuity to take care of you. Something else they can look for: there are signs that can proceed a wound with like a callus. If a diabetic foot problem and an ulcer is like cancer, then a callus is like a breast lump and that's what they can look for (the doctor and the nurse) and that's what you can look for as well on the dermatologic examination.
When you go to see your doctor or your nurse, your nurse practitioner, there's a whole variety of tests that they might do to check on you. But the stuff to do that can identify risk is, thank goodness, really simple. So let's first talk about sensation. One of the things that they'll do is they may check your sensation with something called a monofilament. It looks like a piece of fishing line that you might put on the skin that bends at a certain amount of force and that can tell whether you have so called loss of protective sensation. So in addition to using that wire, another thing that the doctor might do is use a certain kind of vibration test, like a tuning fork or a fancier device that looks like a hairdryer where they might turn up the volume on the thing and it actually can vibrate a little bit more. That's called the vibration perception threshold device. And that can give the doctor or nurse some good information about your degree of sensation. Rarely, they might send you off for special tests like a so-called nerve conduction velocity or other tests like that, but those are rarely performed on someone with diabetes. Still even more rarely are tests where they might take a biopsy of your skin to look under a microscope, to look at the number of little baby nerve fibrils up in there, and to see what the overall population of those are. But the good news about this stuff is it can be done rather rapidly with a lot of low tech and high touch kind of assessment.
Another thing that we can measure and that your doctor might measure is your circulation. Circulation can start with the test of your pulses and he or she may check your foot pulses. There are two main foot pulses: one on the top and one on the side that goes down to the bottom. Those are both checked periodically in a diabetic foot exam. Those can be checked every few months or even once a year by your general doctor, your nurse practitioner, or indeed your foot specialist - your podiatrist.
If there's a problem there, he or she might grab a device called the doppler unit, which is something that is often pocket size that they can take and can actually put on top of the foot or on the side of the foot and it kind of makes it sound like *Whoosh*. Google it and listen for it and you'll be able to see. That can give him or her a wealth of information just by listening to the rate, the rhythm, the breadth of that sound. A really good doctor or nurse or technician can get a lot of information from that. Still more information can be gotten from a fancier version of that doppler, which can be done in a vascular laboratory by specially trained clinicians and technicians who are very skilled in that area. Still other things that can be used to test you are things that can measure tissue oxygenation. There is something called transcutaneous oximetry or tcpO2. That can check the amount of oxygen that's coming off of your skin and your tissue oxygenation. Still something more (just to get fancy) would be something called skin perfusion pressure. That uses a fancy tool called a laser doppler to check your circulation. So you see there's a whole bunch of different things that can be used (and many things I'm not mentioning) but those are just some things that a doctor or a nurse might spout out while he or she is checking you.
There are further tests that might help confirm that there is a problem. For instance, with vascular disease, there might be confirmation that is done not only with more fancy doppler tests that we had discussed, but also maybe a fancy kind of x-ray of your blood vessels called an angiogram or a device like an MRI that can do similar things in different parts of the body to assess this or a special kind of computed tomography or CT angiogram. These are things that could be done if there was a concern of a vascular blockage. If there was a concern further, neuropathy almost always can be checked pretty darn well in the clinic itself and it's unusual to go out for further exams, but you might get something like a nerve conduction velocity or even a skin biopsy to look for the amount of little nerve fibrils in the scan.
What to do if you actually have a wound: now, if you have a wound, it's actually pretty similar to some of the things that are going to be assessed if you were coming in for a screening visit except it's just a little more sense of urgency. If you have a wound now, the things that might put you at greater risk for getting an amputation include infection and ischemia, or bad blood flow. Those things might be checked with a little greater attention and the circulation might be checked using techniques that we have already mentioned like a doppler test, like special other tests like an angiogram or an MRI or a CT angiogram and those will be done by vascular specialists. For checking for an infection, the diagnosis of an infection start and its end is not made with a test. That actual assessment is made by the doctor and he or she looks for clinical signs and symptoms of infection. What might those be? It might be some redness or pus or streaking up your leg or swelling in your lymph nodes or things along those lines. Or - they might order tests like a blood test to look for a high white count (which is the number of white blood cells in a certain volume) or things along those lines, but that starts and ends with the clinical assessment for infection. Other things that the clinician might look for are the size and shape and depth of your wound. They can attest this in a whole variety of ways, but really a lot of this is done just by the good quality clinical examination. The doctor might also photograph your wound or that might also be done by the nurse and that's done so that they can check the wound from week to week or time period to time period and they can look at the overall surface area and size of the wound.
Other things they can look for are: you walking up and down in clinic. They might watch you walk in to see if there are any changes in your gait patterns that might put you at greater risk and other things of that nature. But those are the things that one can assess in a clinical exam and those should just take remarkably a couple of minutes. We've even put it all together - we and some other folks - into what we call a 3 minute foot exam. That foot exam is readily available on the web. You can google that and I'm sure that we can put links to where you can find that so that you can (if you want to) try it at home. Why not? Link to 3 minute foot exam: https://diabetesed.net/wp-content/uploads/2017/05/3-minute-foot-exam.pdf
Before any of these examinations, you probably won't need any special preparations with the exception of: if you were seeing a vascular specialist, that might be more of a procedure and you might not be able to eat the night before, but that would be pretty far down the road before that actually occurred. I'm sure that doctor and all of the other technicians involved will give you good information on that beforehand.
If you show up with a wound, the things that we care about include not only the wound but also the ischemia (or bad blood flow) and the potential for a foot infection. If you add that up, that spells WIFI: Wound, Ischemia, Foot Infection. I want you to think about that now: WIFI. And you have some WIFI settings that you can use. For the wound, the doctor or nurse might assess the wound as mild, moderate, or severe based on certain criteria. They might also assess the ischemia (or the bad blood flow) as mild, moderate, and severe using tests like doppler tests or other tests to look at the amount of oxygen that comes off of your skin. The third thing that they look at - the foot infection - is also based on assessments and tests, and that's none, mild, moderate, and severe and is based not only on the local signs, but also some systemic signs and laboratory signs as well. WIFI - I want you to remember that.
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