<<forEachTiddler  where 'tiddler.tags.contains(context.inTiddler.title)'
sortBy 
        tiddler.title
    ascending 
write '"*[["+tiddler.title+"]]\n"'>>
<<tiddler AutoRefresh with: force>>

Neuropathy - damage to small vessels supplying nerves 
Ischaemia -  atherosclerosis in larger vessels (peripheral vascular disease)
(usually neuropathy first then ischaemia worsens situation)

yearly 5% diabetics develop a foot ulcer, a few of which end up with
amputation

''Managment''
exam - do yearly
shoes temp colour skin pulses (dorsalis pedis and posterior tibial)
sensation (10g monofilament - test in 10 places on foot)
10 places - under big, middle, little toe back a bit on foot in line
with three toes, further back on foot 2 places and one place on heel,
one place on top of foot - if any of the sites aren't felt than the foot
is neuropathic
Monofilament - use at right angles to foot, bend it 1 cm and keep it
there for 2-3 secs, can be used on 10 patients in one session and then
has to be left for 24 hours to recover its buckleability

''ask'' - pain - exercise/rest, numbness/tingling, soreness/irritation, 
shoes, how do you look after - check footwear when putting on, don't walk barefoot, 
wash and moisturize feet daily, examine daily for irritation, cut nails straight, see chiropodist for calluses

''assess risk''
//low - educate and yearly check//
//moderate// - any of - sensation, deformity, loss of pulse or vision - //chiropody every 1-3/12//
//high// if previous ulcer, amputation, callus with neuropathy, pulseless or
deformity, or pulseless and neuropathy - //chiropody by diabetic team and orthotic referral//
active disease - painful neuropathy difficult to control - needs urgent
referral to diabetic MDT - ulcer, osteomyelitis, charcots foot

''Ulcers''
//Neuropathic// - deep and painless, punched out edge, over bony prominence
//Arterial// - painful with poor capillary return and cold foot, punched out
edge, all over
new ulcer needs assesment and treatment within 24hours by specialist MDT

''Osteomyelitis''
urgent care - diabetics, microbiologist, surgeons
MRI more useful than Xray on which it takes time for changes to occur

''Charcots joint''
after 10-15 years of diabetes
neuropathic and osteoporotic feet become deformed - maybe after minor
unnoticed trauma
early stage may be warm and red but not painful
later on deformed with loss of plantar arch
Rx - difficult - MDT, rest, immobilise, reduce weight bearing stress