History and Physical Examination
Core concepts
The history drives most of the diagnosis in podiatric practice. Master the characterization of pain (onset, location, radiation, quality, severity, timing, aggravating and relieving factors), the review of systems relevant to the foot (vascular, neurologic, dermatologic, rheumatologic), and the risk stratification of every patient for peripheral arterial disease, neuropathy, and infection. Understand the diabetic foot examination: monofilament testing, vibration perception, pedal pulses, capillary refill, ankle-brachial index indications, and inspection of pressure points. Know normal versus abnormal ranges for pulses, temperature, and sensation, and the significance of hair loss, shiny skin, and dependent rubor as chronic ischemia signs.
Traps in questions
A common trap is confusing neuropathic pain (burning, nighttime, stocking distribution) with ischemic rest pain (worse with elevation, relieved by dependency). Another is missing a systemic cause-gout, rheumatoid arthritis, or referred lumbar pain-when the foot findings are obvious. Questions often reward the next best step rather than the diagnosis. Remember that a normal monofilament test does not exclude neuropathy; it screens for loss of protective sensation only.
Rule of thumb
In any patient with a foot complaint and diabetes, vascular status and sensation must be documented before any local intervention is considered. If a question asks for the most important initial step, choose a thorough neurovascular examination.
Worked example
A 62-year-old with diabetes reports burning in both feet at night. Exam shows absent vibration sense, intact monofilament, and bounding pulses. The diagnosis is distal symmetric polyneuropathy; the intact monofilament does not rule it out.