Type 2 Diabetes Glucose Control Menu Over
Front of Type 2 Diabetes and Glucose Control algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Glucose_508c.pdf
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Type 2 Diabetes Glucose Control Back
Back of Type 2 Diabetes and Glucose Control algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Glucose_508c.pdf
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Type 2 Diabetes and Insulin Menu Over
Front of Type 2 Diabetes and Insulin algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Insulin_508c.pdf
IHS Division of Diabetes
Type 2 Diabetes and Insulin Back
Back of Type 2 Diabetes and Insulin algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Insulin_508c.pdf
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Type 2 Diabetes - Lipid and Aspirin Therapy Menu Over
Front of Type 2 Diabetes - Lipid and Aspirin Therapy algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Lipids_508c.pdf
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Type 2 Diabetes - Lipid and Aspirin Therapy Back
Back of Type 2 Diabetes - Lipid and Aspirin Therapy algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Lipids_508c.pdf
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Neuropathy and Type 2 Diabetes Menu Over
Front of Type 2 Diabetes - Neuropathy algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Neuropathy_508c.pdf
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Neuropathy and Type 2 Diabetes Back
Back of Type 2 Diabetes - Neuropathy algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Neuropathy_508c.pdf
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Chronic Kidney Disease and Type 2 Diabetes Menu Over
Front of Type 2 Diabetes - Chronic Kidney Disease algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_CKD_508c.pdf
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Chronic Kidney Disease and Type 2 Diabetes Back
Back of Type 2 Diabetes - Chronic Kidney Disease algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_CKD_508c.pdf
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Urine Albumin Screening and Monitoring in Type 2 Diabetes Menu Over
Front of Urine Albumin Screening and Monitoring in Type 2 Diabetes algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Urine_Alb_508c.pdf
IHS Division of Diabetes
Urine Albumin Screening and Monitoring in Type 2 Diabetes Back
Back of Urine Albumin Screening and Monitoring in Type 2 Diabetes algorithm card. Source: http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_Urine_Alb_508c.pdf
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Diabetes FootCare Algorithm
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Initial Exam

image of hands inspecting bare foot soles

Remove shoes at each visit
Inspect feet for acute problems
Dr Stephen Rith-Najarian MD
Cass Lake MN


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No Ulcer

*Perform*
Annual Foot Exam
Monofilament Exam
Sensory Exam
Inspect for Deformity
History of Ulcer or Amputation

Complete Diabetic
Foot Exam

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Monofilament Exam

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Vibration Sensation Exam

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Ulcer Found

Debridement
Blood count
Temperature
Wound culture
Assess circulation

Uncomplicated --- Complicated







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Low Risk
Normal Exam
green line

Focus On:

Follow-up:






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High Risk
Abnormal Exam
red line

Focus On:

Follow-up:





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< 2 cm
Uncomplicated
Ulcer
orange line

*Weekly visits until healed then treat as high risk
*If failure to improve in 4 weeks-treat as complicated ulcer





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> 2 cm
Complicated
Ulcer
red line

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Foot Ulcer

Diagnostic Features
Neuropathic
Ischemic
2011 ADA Foot Care
Recommendations
Dr. Gregory M. Caputo, MD, FACP
Penn State Hershey
Milton S. Hershey Medical Center

IHS Division of Diabetes


Neuropathic vs Ischemic

Neuropathic

Ischemic

Painless Painful
Normal pulses Absent pulses
Typically
punched out
appearance
Irregular
margins
Often
located on
plantar surface
Commonly
located on
toes, glabrous
margins
Calluses present Calluses absent
or infrequent
Loss of
sensation,
reflexes and
vibration
Variable
sensory
findings
Increase
in blood
flow
Decrease
in blood
flow
(AV shunting)
Dilated veins
Collapsed
veins
Dry, warm
foot
Cold foot
Bony
deformities
No bony
deformities
Red
appearance
Pale,
cyanotic
IHS Division of Diabetes

ADA Foot Care
Recommendations

Comprehensive Foot Exam

  • For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations
  • Inspection
  • Assessment of foot pulses

Test for...

  • Test for loss of protective sensation: 10-g monofilament plus testing any one of
  • Vibration using 128-Hz tuning fork
  • Pinprick sensation
  • Ankle reflexes
  • Vibration perception threshold

Education

  • Provide general foot self-care education
  • All patients with diabetes

Multidisciplinary Approach

  • Use multidisciplinary approach
  • Individuals with foot ulcers
  • High-risk feet; especially prior ulcer or amputation

Refer

  • Refer patients to foot care specialists for
  • Ongoing preventive care
  • Life-long surveillance
  • Smokers
  • Loss of protective sensation or structural abnormalities
  • History of prior lower-extremity complications

Peripheral Arterial Disease

  • Initial screening for peripheral arterial disease (PAD)
  • Include a history for claudication
  • Assessment of pedal pulses
  • Consider obtaining an ankle-brachial index (ABI)
  • Many patients with PAD are asymptomatic

Claudication or Positive ABI

  • Refer patients with significant claudication or a positive ABI for further vascular assessment
  • Consider exercise, medications, surgical options
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Neuropathic Ulcer

image of neropathic foot ulcer

"It's not what you put on a wound,
it's what you take off."

Pressure relief - Debridement

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Neuropathic Ulcer
No Apparent
Infection

- Debridement
- Dressings
- Pressure relief
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Neuropathic Ulcer
Mild Infection

- Debridement
- Dressings
- Pressure relief
- Oral antibiotics
- Close follow-up
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Neuropathic Ulcer
Moderate-Severe
Infection

- Admission
- Immediate surgical consultation
- Surgical drainage
- Debridement
- IV antibiotics
- Wound care
- Pressure relief

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Neuropathic Ulcer
Osteomyelitis

Reference

IHS Division of Diabetes

Reference

Butalia et al JAMA. 2008 299(7):806-13.
Does this patient with diabetes have osteomyelitis of the lower extremity?
Toronto, Canada

Severe Infection
Signs and
Symptoms

Severe if:

Reference
IHS Division of Diabetes

Reference

Curr Diab Rep. 2003 Dec;3(6):475-9.
The international consensus and practical guidelines on the management and prevention of the diabetic foot.
Schaper NC, Apelqvist J, Bakker K.
Department of Endocrinology, University Hospital Maastricht, The Netherlands.

Mild Infection
Antimicrobial
Agents

Microbiology: Consider for empiric treatment: Duration of antibiotics:
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Severe Infection
Antimicrobial
Agents

Microbiology: Consider for empiric treatment: Duration of antibiotics:
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Ischemic Ulcer

image of ischemic foot ulcer
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Ischemic Ulcer
No Apparent
Infection

Initial wound management:

Recommend referral for specialty consultation

IHS Division of Diabetes

Ischemic Ulcer
Mild Infection

Initial wound management:

Recommend referral for specialty consultation

IHS Division of Diabetes

Ischemic Ulcer
Moderate-Severe
Infection

Initial wound management:

Recommend referral for specialty consultation

IHS Division of Diabetes

Ischemic Ulcer
Osteomyelitis

Reference

IHS Division of Diabetes