NURS 505 Week 6 Discussion Board Forum 2 on the Diabetic Foot Sensory Examination Example

Discussion Board Forum 2: Applying the Neurologic and Musculoskeletal Examination to the Diabetic Foot

NURS 505 Advanced Health / Physical Assessment, Discussion Board Forum 2

Thread by [Student Name]

The patient example and the classmates replied to are composites written for a model discussion.

Of all the neurologic examinations in this week's chapters, the one I expect to perform most often as a nurse practitioner takes five minutes and needs a nylon filament and a tuning fork. It is the sensory examination of the feet in people with diabetes, and it is skipped far more often than it should be.

Consider a composite patient, 61, with type 2 diabetes for twelve years, who mentions in passing that shoes "feel strange" at the end of the day. The examination begins with inspection: dry, cracked skin at the heels, a callus under the first metatarsal head and thickened toenails. Structure matters too, since a prominent bunion or hammertoes create pressure points. Pedal pulses are palpated at the dorsalis pedis and posterior tibial arteries; here they are present but diminished on the left. Then comes sensation. A 10-gram monofilament is pressed against the plantar surface at several sites until it buckles, with the patient's eyes closed, and the patient says yes each time the touch is felt (Bickley et al., 2021). Our patient misses three of four sites on the left foot. When the vibrating 128-Hz fork rests on the big toe's joint, the patient stops feeling it well before the examiner's own finger does.

Those two findings together mean the patient has lost protective sensation, and a stone in the shoe could become an ulcer before it is ever felt. The ADA Standards of Care recommend that people with diabetes have a comprehensive foot evaluation at least annually, covering a look at the skin and structure, a check of the pulses, and a monofilament screen combined with one or more other sensory checks, such as vibration, pinprick, temperature or ankle reflexes (American Diabetes Association Professional Practice Committee, 2026). Patients with loss of protective sensation should have their feet inspected at every visit.

The findings change the plan immediately. Our patient needs education on daily self-inspection with a mirror, never walking barefoot, checking bath water with an elbow and wearing well-fitted shoes; a referral to podiatry for the callus and nails, and possibly for therapeutic footwear; and an ankle-brachial index for the weak pulse. Glucose control and smoking status, if relevant, become even more important.

The broader lesson is that a physical examination technique only matters if it is done. Building the foot examination into the annual diabetes visit template, and removing patients' shoes and socks at check-in, are simple system changes that make the examination routine rather than optional.

Reply to Rachel

Rachel, your point that many patients with neuropathy have no symptoms is exactly why the examination cannot wait for complaints. I would add one step after the examination: assigning a risk category. The ADA Standards of Care describe stratifying foot risk using findings such as loss of protective sensation, peripheral artery disease, foot deformity and a history of ulcer or amputation, with higher-risk patients needing more frequent examinations and specialist involvement (American Diabetes Association Professional Practice Committee, 2026). In practice, a patient with loss of sensation and a deformity, like the bunion you described, belongs in a higher category than one with neuropathy alone. Recording the category in the problem list helps every clinician who sees the patient know how closely to watch the feet. Your suggestion that medical assistants remove shoes and socks at rooming fits well with this, because the examiner then has no barrier to looking. Did your clinic find that patients resisted taking off their shoes? Some of ours did until we explained why, after which most were glad someone was paying attention.

Reply to Kevin

Kevin, I appreciated your honest comment that you had been using the monofilament on only one site per foot because of time. A full examination does not take much longer once it becomes routine. The textbook describes testing several plantar sites on each foot and avoiding calluses, which can mask sensation and give a false result (Bickley et al., 2021). One practical tip is to use a laminated diagram of the foot in the room and mark missed sites directly, then document "loss of protective sensation present or absent" with the number of sites felt, which makes comparison at the next visit easy. Another is to replace monofilaments regularly, since they lose stiffness with repeated use and can underestimate loss. Your idea of teaching patients to check their own feet with a mirror each night is the most important part of the plan, because no clinician sees the feet every day. Have you found any educational materials patients actually keep and use at home?

References

American Diabetes Association Professional Practice Committee. (2026). 12. Retinopathy, neuropathy, and foot care: Standards of Care in Diabetes 2026. Diabetes Care, 49(Suppl. 1), S261-S276. https://doi.org/10.2337/dc26-S012

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.