What is the immediate next step for a 70-year-old patient, a chronic smoker, with a history of type 2 diabetes, presenting with transient twisting of the right hand index and little finger and right foot last three toes?

Immediate Next Step: Comprehensive Foot and Neurological Examination

The immediate next step is to perform a comprehensive foot examination including inspection of the skin, neurological assessment with 10-g monofilament testing plus at least one additional test (pinprick, temperature, or vibration), and vascular assessment of lower extremity pulses. 1

Clinical Context and Urgency

This patient presents with concerning symptoms that suggest diabetic peripheral neuropathy (DPN) affecting specific digits in a non-anatomical distribution. The combination of:

• Age >70 years
• Chronic smoking history
• Long-standing type 2 diabetes
• Transient "twisting" of specific fingers and toes

...creates a high-risk profile requiring immediate systematic evaluation. 1

Structured Examination Protocol

1. Neurological Assessment (Primary Focus)

Perform loss of protective sensation (LOPS) testing immediately, as peripheral sensory neuropathy is the single most common component cause for foot ulceration (present in 78% of diabetic foot ulcers). 1

Required testing includes:

• 10-g monofilament test starting distally on the dorsal aspect of the hallux bilaterally, moving proximally until threshold is detected 1
• Plus at least one additional test: pinprick sensation, temperature perception, vibration with 128-Hz tuning fork, or ankle reflexes 1
• Absent monofilament sensation plus one other abnormal test confirms LOPS 1

2. Skin and Structural Inspection

Examine for:

• Skin integrity and breakdown
• Foot deformities (bunions, hammertoes, prominent metatarsals, Charcot changes) 1
• Pre-ulcerative signs on affected digits (index finger, little finger, last three toes) 1
• Evidence of prior ulceration or amputation 1

3. Vascular Assessment

Critical given smoking history:

• Palpate dorsalis pedis and posterior tibial pulses bilaterally 1
• Assess capillary refill time 1
• Check for rubor on dependency and pallor on elevation 1
• Evaluate venous filling time 1

If pulses are diminished/absent or patient reports leg fatigue or claudication, refer immediately for ankle-brachial index testing. 1

4. Obtain Targeted History

Document:

• Current neuropathic symptoms: pain, burning, numbness in the affected digits 1
• Vascular symptoms: leg fatigue, claudication, rest pain 1
• Prior history of ulceration, amputation, or Charcot foot 1
• Exercise tolerance and smoking quantity 1

Critical Risk Stratification

This patient meets multiple high-risk criteria requiring specialist referral:

• Chronic smoker with diabetes 1
• Age >70 years
• Symptoms suggesting LOPS
• Likely structural abnormalities given symptom distribution

The American Diabetes Association mandates that individuals who smoke and have prior lower-extremity complications, LOPS, structural abnormalities, or peripheral arterial disease must be referred to foot care specialists for ongoing preventive care and lifelong surveillance. 1

Common Pitfalls to Avoid

• Do not rely on patient-reported symptoms alone - up to 50% of patients with significant neuropathy are asymptomatic 1
• Do not skip vascular assessment - smoking dramatically increases peripheral arterial disease risk, which combined with neuropathy creates the highest amputation risk 1, 2
• Do not delay specialist referral - the triad of peripheral sensory neuropathy, minor trauma, and foot deformity is present in >63% of diabetic foot ulcerations 1
• Do not perform only annual screening - patients with evidence of sensory loss require foot inspection at every visit 1

Immediate Management Considerations

While completing the examination:

• Educate on daily foot self-inspection using mirrors for areas not easily visible 1
• Emphasize proper footwear - never walk barefoot, in socks only, or in thin-soled slippers 1
• Initiate smoking cessation counseling immediately, as smoking with diabetes creates synergistic cardiovascular and microvascular risks 1
• Ensure proper footwear is worn during examination and provide therapeutic footwear recommendations if deformities are present 1

The examination findings will determine whether same-day specialist referral, urgent vascular studies, or immediate wound care intervention is required. 1, 2