Diabetic Foot Exam OSCE

Diabetic Foot Examination

Case Studies

Patient Brief Record / Brief Scenario

Information for student about the case

• Patient Name: mohammad
• Age: 40 years
• Occupation: Secretary in a private company
• No frequent visits to the clinic
• Lab investigations performed outside showed FBS: 9.00 mmol/l.
• FBS done here showed: 10.1 mmol/l (181.8 mg/dl)
• Today:
  • BP: 120/80
  • Weight: 70 kg
  • Height: 160 cm

mohammad is a 40-year-old man who came with the complaint of polyuria and increased thirst.

TASK: (What is expected from a student?)

1. Take a focused and relevant history to help diagnose and manage the patient’s problem.
2. Perform the relevant clinical examination and examine the patient’s feet.
3. Inform the patient about the diagnosis.
4. Explain to the patient the management plan.
5. Write a referral letter for the patient to a relevant specialist.

Patient’s Scenario/ Instructions to Patient

You are a 40-year-old man who works as a secretary in a private company. You have come to the clinic today with the complaint of polyuria and increased thirst. You have done your fasting blood sugar, which was high. You were informed about the possibility of being diabetic.

Opening scenario: You have come to see your results of blood sugar, as you have increased thirst and urination (You will admit only this).

Tell your doctor about the following information only if specifically asked about:

• The symptoms of polyuria and increased thirst started 2-3 weeks ago.
• Apart from increased micturition and thirst, you do not feel any other symptoms.
• You do not use any medication.
• You are a non-smoker.
• Your mother is diabetic and had two toes amputated and renal failure. She is on dialysis.
• Your father is hypertensive.
• No recent investigations have been performed apart from fasting blood sugar.
• You are not known to have any other chronic illnesses.
• You do not perform any regular exercise.
• Patient’s idea: It is a serious problem.
• Concern: Like your mother, you will suffer from complications.
• Expectation: To get medication that will save you from complications.
• Any other points, please relate to your own personal and family history.

Important Notes for the SP:

• You have come to recheck today to see if you are diabetic or not.
• The student will examine your feet and perform other simple clinical examinations.
• Any other information should be given to the doctor only when he asks you.

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Diabetic Foot Exam

Examination Steps & Checklist

Introduction & Preparation

• Introduce yourself to the patient (e.g., name, role).
• Confirm patient identity.
• Establish rapport properly and use appropriate communication skills.
• Explain what you want to do (foot examination), the steps involved, and responses expected.
• Take permission/consent to conduct the foot examination.
• Wash hands (alcohol rub) before and after the examination.
• Ensure privacy.
• Expose the patient’s lower legs and feet adequately. Ensure good lighting.

Inspection

• General: Inspect both feet, including soles, heels, between the toes.
• Skin:
  • Color (pallor, erythema).
  • Skin changes (e.g., dryness, cracking, thinning, hair loss).
  • Specific diabetic skin lesions (e.g., Granuloma annulare, Necrobiosis lipoidica).
  • Calluses, corns.
  • Signs of infection (e.g., fungal infection like tinea pedis, bacterial infection like cellulitis or paronychia).
• Nails: Check for thickening, fungal infection, ingrown toenails.
• Musculoskeletal:
  • Deformities (e.g., Charcot foot, hammer toes, claw toes, bunions).
  • Muscle wasting.
• Ulcers: If present, describe thoroughly:
  • Site: Precise location.
  • Size: Measure dimensions (length, width).
  • Shape: Outline.
  • Surface/Base: Appearance (e.g., granulation tissue, slough, necrotic tissue, exposed tendon/bone).
  • Edges: (e.g., punched out, sloping, undermined, rolled).
  • Depth: Estimate or probe gently (with sterile instrument if appropriate).
  • Surrounding Tissue: Signs of inflammation, maceration, callus.
  • Tenderness: Assess on palpation around the ulcer.
  • Underlying Structure: Palpate base for hardness (bone).
  • (Summarized as 5S TUBED: Site, Size, Shape, Surface, Surrounding tissue; Tenderness, Underlying structure, Base, Edges, Depth).
• Gait: Ask the patient to walk a short distance. Observe for abnormalities (e.g., limp, antalgic gait, foot drop, broad-based gait).
• Footwear: Inspect the patient’s shoes (inside and out) for:
  • Appropriate size and fit.
  • Signs of abnormal wear.
  • Presence of foreign objects.
  • Adequate support and protection.

Palpation

• Temperature: Assess skin temperature using the back of your hand, comparing both feet and different areas of the same foot (e.g., dorsal vs. plantar, distal vs. proximal). Note any coolness or warmth.
• Capillary Refill: Press on the nail bed or pulp of the toe for 5 seconds and note the time taken for color to return (Normal < 2-3 seconds).
• Pulses: Palpate peripheral arteries of both feet:
  • Dorsalis Pedis artery.
  • Posterior Tibial artery.
  • If distal pulses are not palpable, attempt to palpate the Popliteal artery.
• Tenderness: Palpate gently for any tender areas, especially over bony prominences, calluses, or joints.
• Edema: Check for pitting edema over the dorsum of the foot, around the ankles, and extending up the shin.
• Callosities: Note location and thickness.

Neurological Examination

• Sensory Testing:
  • Light Touch: Use cotton wool or a light brush on dorsal and plantar aspects.
  • Pain Sensation (Pinprick): Use a sterile neurotip or pin. Test distally (e.g., dorsum of great toe) and compare proximally. Ask patient to differentiate sharp vs. dull.
  • Vibration Sensation: Use a 128 Hz tuning fork. Place firmly on bony prominences, starting distally (e.g., IP joint of great toe). Ask patient when vibration starts and stops. If absent distally, move proximally (e.g., medial malleolus, tibial tuberosity). Compare sides.
  • Proprioception (Joint Position Sense): Hold the sides of the great toe. Demonstrate ‘up’ and ‘down’ movement with patient’s eyes open, then ask them to identify the direction with eyes closed.
  • Pressure Sensation (10g Monofilament): Crucial test for protective sensation.
    • Explain the test: “I’m going to touch your foot with this filament. Say ‘yes’ each time you feel it.”
    • Apply perpendicular to the skin with enough force to buckle the filament for ~1 second.
    • Test specific sites (e.g., plantar aspect of 1st, 3rd, 5th metatarsal heads; plantar aspect of great toe; heel). Avoid callused areas.
    • Test on dorsum first so patient knows what to expect.
    • Loss of sensation indicates risk of ulceration.
• Motor Examination:
  • Tone: Assess resistance to passive movement at the ankle and foot joints.
  • Power: Test strength against resistance for:
    • Ankle Dorsiflexion (Tibialis anterior, L4/L5).
    • Ankle Plantarflexion (Gastrocnemius/Soleus, S1/S2).
    • Toe Extension/Flexion.
• Reflexes:
  • Ankle Jerk (Achilles Reflex): Tap the Achilles tendon (S1 nerve root). Can be reinforced by asking patient to hook fingers and pull.
  • Knee Jerk (Patellar Reflex): Tap the patellar tendon (L3/L4 nerve root). (Often included for completeness).

Musculoskeletal Examination

• Joint Movement: Assess active and passive range of motion of the ankle, subtalar, and toe joints. Note any limitation or pain. (Partially covered by proprioception and motor exam).

Conclusion & Communication

• Cover the patient.
• Share/explain the findings of the examination with the patient in clear, understandable language.
• Summarize the findings (e.g., “On examining your feet, mohammad, I found [mention key findings like good pulses, loss of sensation with monofilament, presence of callus, etc.]”).
  • Example Summary Structure:
    1. “Today I examined mohammad, age 40.”
    2. “Inspection showed [e.g., no ulcers, mild dryness]. Gait was normal. Palpation revealed warm feet with good pulses (Dorsalis Pedis and Posterior Tibial palpable bilaterally). Neurological exam showed [e.g., intact light touch and pain, vibration sense present distally, but loss of protective sensation to the 10g monofilament at the first metatarsal head bilaterally]. Ankle reflexes were present.”
• Provide advice on diabetic foot care (e.g., daily inspection, proper washing/drying, appropriate footwear, nail care, avoiding walking barefoot, seeking prompt attention for injuries).
• Ask the patient if they have any questions.
• Thank the patient.
• Inform the patient about the next steps (e.g., discussion of overall diabetes management, referral, follow-up visit date).
• Wash hands.
• Mention further actions: “To complete my assessment, I would review blood glucose control (FBS, HbA1c), assess overall cardiovascular risk factors, and consider referral to a podiatrist/diabetic foot clinic if significant pathology is found.”

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OSCE Checklist Summary Points

• Establishes rapport, explains, gets permission, washes hands.
• Inspects foot (dermatological, musculoskeletal), asks patient to walk, examines shoes.
• Palpates (temperature, callosities, edema, pulses - DP, PT, Popliteal if needed).
• Tests joint movement (proprioception).
• Assesses sensation (pressure - 10g monofilament, pain - pinprick, vibration - 128Hz tuning fork).
• Performs ankle jerk reflex testing.
• Shares findings, explains, thanks patient, asks questions, informs about follow-up.
• Summary:
  1. Today I examined [Name], [Age]…
  2. There’s no abnormality / There is [finding]… Normal gait…
  3. I will complete my exam by [e.g., full vascular/neurological assessment if needed], advise on foot care, review blood glucose…
  4. If there’s any pathology suspected I would like to ask for more investigations [e.g., HbA1c, Doppler US, X-ray]…

Attachments

OSCE - Diabetic Foot Examination

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Investigations (Related to Case/Diabetes)

• Fasting Blood Sugar (FBS)
• Glycated Hemoglobin (HbA1c)
• (Consider others based on overall assessment: Renal function tests, Lipid profile, Urine for microalbuminuria)

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Management Principles

• Explain diagnosis of Diabetes Mellitus based on history and investigations.
• Discuss management plan including:
  • Lifestyle modification (diet, exercise, weight management).
  • Blood glucose monitoring.
  • Medication (if indicated).
  • Foot care education (as detailed above).
  • Management of other cardiovascular risk factors (BP, lipids).
  • Regular follow-up and screening for complications.
• Address patient’s Ideas, Concerns, Expectations (ICE).
• Write referral letter (e.g., to Diabetes Specialist Nurse, Dietitian, Podiatrist, Endocrinologist as appropriate).

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Doctor/Patient Interaction / Effective Use of Consultation

• Establish Rapport: Use appropriate non-verbal behavior (eye contact, posture, position, movement, expression). Show interest, concern, and respect.
• Gather Information:
  • Use open-ended and closed questions appropriately.
  • Listen attentively, allow patient to complete statements, use silence effectively.
  • Facilitate responses verbally and non-verbally (encouragement).
• Understand Patient’s Perspective: Explore Ideas, Concerns, and Expectations (ICE).
• Share Information:
  • Use concise, easily understood language; avoid or explain jargon.
  • Periodically summarize to verify understanding and invite corrections/additions.
• Shared Decision Making: Involve the patient in management planning.
• Structure & Timing: Manage consultation time effectively.