Look for signs of neuropathy

Other parts of the physical exam aimed at preventing end-organ complications are the neurologic and foot exams. One thing patients fear when they come to grips with their diabetes diagnosis is limb amputation. Many patients remember from childhood a relative who had diabetes and was an amputee, or they have current acquaintances who have required amputations. Because amputees almost always have severe peripheral vascular disease as well, they are likely to also conjure up in patients’ minds other end-organ diseases, such as MI or stroke.

Figure 2. Semmes-Weinstein monofilament test sitesI spend part of an appointment reviewing with patients the benefits of at-home foot exams. While examining their feet in the office, I reinforce to them how easy and quick the process is and how they can do the same exam at home on a regular basis. Many of our patients have trouble bending over to see the bottoms of their feet because of obesity, arthritis, or a combination of the two. For them, I recommend placing a handheld mirror on the floor or leaning it up against a wall, so that they can inspect their feet, soles, and toes. If a patient has impaired vision, I try and encourage a loved one/relative or visiting nurse (who often has had to accompany the patient to the visit and is present in the exam room) to inspect the feet on a regular basis—usually daily during dressing or bathing. Patients often ask: “What am I looking for?” The short answer is: “Anything you think is dangerous or shouldn’t be there.” But scratches, bleeding, or cracks in the skin that don’t appear to be healing should be shown to a health-care professional immediately. The monofilament exam test helps determine which patients are at even higher risk for ulcers and amputation; those who cannot feel the monofilament at the sites shown in Figure 2 should be told in detail that just as they can’t feel the filament, they might not feel a cut, ulcer, pebble, or even a metal nail touching their foot. The foot exam also is an opportunity to refer appropriate patients to a podiatrist for help with more suitable shoes and better overall foot hygiene (e.g., nail trimming and callus management).

The most important aspect of the foot exam is to do it; I cannot emphasize this enough. I am often stunned when a new patient with a history of diabetes emerges from the changing area wearing only an examination gown and socks on their feet. When questioned, these patients invariably report that their feet were not included in regular examinations by previous clinicians and that they do not perform home foot exams on a routine basis. This immediately tells me that the patient has not been taught about the importance of regular foot examination—performed by either the provider or the patient. The reason I do a foot exam is to reinforce its importance to the patient. An early-stage abrasion or foot ulcer is certainly easier to treat than a deeper one, and it’s less likely to result in surgery and/or amputation. One of the more rewarding experiences I’ve had came when a longtime patient questioned why I had not examined his feet. He was right in demanding a foot exam, and this told me that I had been effective at communicating the importance of the foot and neurologic exams at previous visits.

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Keeping an eye on kidneys

Another major concern on the minds of patients who have any personal or familial experience with diabetes is kidney disease and dialysis (Figure 3). All patients who have had diabetes (type 1 or 2) for at least five years should have urine microalbumin testing on a yearly basis.The rationale for this is that the earliest damage from diabetic nephropathy can be detected by increased spillage of albumin in the urine. The routine urine dipstick used by many clinicians is an insensitive test for this, detecting urine protein only when the excretion rate is >300 mg/day—about 10-15 times the normal rate in someone with a pair of healthy kidneys. A spot or random urine protein measurement of >30 µg albumin/mg urine creatinine on a persistent basis almost always indicates early diabetic kidney disease. I use this test and the rationale for its use as a paradigm for most end-organ diseases associated with diabetes. I explain to patients that the usual urine test or measure of overall kidney function with a serum creatinine will pick up kidney disease only at a more advanced stage. We have known for many years the benefits of ACE inhibitors and angiotensin receptor blockers on slowing the progression of diabetic nephropathy in patients with microalbuminuria (i.e., urine microalbumin/creatinine ratios of >30 µg/mg). Therefore, detecting damage to the nephron at an early stage, like early detection of neuropathy and eye disease, enables us to target individual patients who may benefit from specific interventions, which may be behavioral, medical, or both.