1. Every 30 seconds a lower limb is lost somewhere in the world as a consequence of Diabetes. The Lancet Volume 366 Issue 9498

2. Nice Guideline CG10 Foot care Recall and annual review to detect risks Exam, Test, Palpate, Inspect, Classify

3. How to screen and categorise your patient. Annual Screening Review

4. The Diabetic Foot Peripheral Vascular Disease Important cause of amputation Causative factor of ulceration in 38-52% 50% of all Diabetic amputations (Pacaudet et al 1999)

5. The Diabetic Foot Peripheral Neuropathy Peripheral neuropathy varies from 12-50% Young et al 1993 – 28.5% in 6500 pts Testaye et al 1996 – 28% Dyck et al 1993 – 13% symptomatic 50% clinical evidence

6. The Diabetic Foot If can’t feel pressure:- - x10 increased risk of foot ulcer or amputation If also foot deformity x32 increased risk Rith Najarian 1992

7. What do we need to screen a patient? Eyes Hands 10g Monofilament Annual Screening review

9. Annual Screening Review Examination Skin Condition Pulses present Sensitive to 10g pressure (loss of 10g = HIGH RISK of ulceration Symptoms Claudication Pain History of ulcer Visual impairment Mobility problems Inspection Callus Deformity Ulcer present

11. Annual Screening Review Examination Skin Condition Pulses present Sensitive to 10g pressure (loss of 10g = HIGH RISK of ulceration Symptoms Claudication Pain History of ulcer Visual impairment Mobility problems Inspection Callus Deformity Ulcer present

12. To palpate pulses use 2 fingers not your thumb. Dorsalis Pedis Pulses – can be found in the groove between the 1st and 2nd Metatarsal bones This pulse can be absent in 10% of people Posterior Tibial Pulse – can be found behind the medial malleolus 1/3 of the distance from the medial malleolus to the bottom of the heel, in a hollow. Annual Screening Review

13. Avoid areas of callus or ulceration Deteriorates with use Not to test on more than 10 patients with each monofilament per session Monofilament requires 24hr rest. Use approved monofilaments either Bailey’s or Owen Mumford Neuropen Demonstrate on patients forearm or face to ensure they know how it feels. Ask patient to close their eyes before you start and answer YES each time they feel it. Place the tip of the monofilament on the site to be tested. Apply pressure until it bows. Don’t let it slip or slide across the skin or make repetitive contact with the same spot. Test all sites on the screening form. Annual Screening Review

15. Protective sensation intact (10g monofilament) Annual Screening Review Low Risk Normal Flow

16. Moderate Risk +/- arterial disease Loss of protective sensation (10g pressure) No deformity No callus No previous ulcer Annual Screening Review

17. High Risk +/- arterial disease Loss of protective sensation(10g pressure) Deformity or callus present No previous ulcer Annual Screening Review

18. Very High Risk +/- arterial disease Ulcer present Previous ulcer Loss of protective sensation (10g pressure) Annual Screening Review

19. Arterial Disease Abnormal flow +/- history of claudication Annual Screening Review