Fig. 10.15 Diabetes and the skin. A Acanthosis nigricans.
B Necrobiosis lipoidica. C Eruptive xanthomata.
10.7 Investigations in diabetes
Investigation Indication/comment
To make a diagnosis of diabetes.
Patients will also monitor capillary blood
glucose to adjust their treatment
HbA1c Can be used for diagnosis of type 2
diabetes and to assess glycaemic burden
Ketones suggest insulin deficiency,
which occurs in type 1 diabetes and in
diabetes due to pancreatic pathology
To confirm a diagnosis of autoimmune
HbA1c An important measure of glycaemic
control over the preceding 3 months;
predicts risk of complications
Urea and electrolytes To assess for the presence of diabetic
Lipid profile To aid estimation of cardiovascular risk
and guide treatment with lipid-lowering
Thyroid function tests To screen for the commonly associated
To assess for early signs of diabetic
nephropathy (microalbuminuria)
To screen for diabetic retinopathy and/or
GAD, glutamic acid decarboxylase.
and the best sites to test are shown in Fig. 10.17. Avoid
areas of untreated callus. Sensory loss typically occurs in
• Assess dorsal column function by testing vibration and
• Undertake a foot risk assessment to guide management
Hair loss and nail dystrophy occur with ischaemia. Feet are
warm in neuropathy and cold in ischaemia. Ischaemic ulcers are
typically found distally: at the tips of toes (see Fig. 10.16B), for
example. There may be skin fissures or tinea infection (‘athlete’s
foot’). Loss of sensation to vibration (p. 143) and proprioception
(p. 144) are early signs of diabetic peripheral neuropathy. Sensory
neuropathy is present if the patient cannot feel the monofilament
on the sites shown in Fig. 10.17. This suggests loss of protective
pain sensation and is a good predictor of future ulceration.
With significant neuropathy, the foot arch may be excessive or
collapsed (rocker-bottom sole). Both conditions cause abnormal
pressures and increase the risk of plantar ulceration (see Fig.
10.16C), particularly in the forefoot. Charcot’s arthropathy is
disorganised foot architecture, acute inflammation, fracture and
bone thinning in a patient with neuropathy. It presents acutely
as a hot, red, swollen foot and is often difficult to distinguish
10.8 Risk assessment of the diabetic foot
Level of risk Definition Action required
High Previous ulceration or amputation, or more than one risk factor
Annual screening should be undertaken by a specialist
Active foot disease Ulceration, spreading infection, critical ischaemia or an
unexplained red, hot, swollen foot
Prompt referral to a multidisciplinary diabetic foot team is
Fig. 10.16 Diabetic foot complications. A Infected foot ulcer with
cellulitis and ascending lymphangitis. B Ischaemic foot: digital gangrene.
C Charcot arthropathy with plantar ulcer.
Fig. 10.17 Monofilament sensory testing of the diabetic foot.
A Apply sufficient force to allow the filament to bend. B Sites at highest
risk (toes and metatarsal heads).
The physical examination • 209
Please examine her thyroid status
• Introduce yourself and clean your hands.
• Palpate the pulse for bounding pulse, tachycardia and atrial fibrillation.
• Test eye movements for ophthalmoplegia and lid lag.
• Auscultate any goitre for bruit.
• Examine the shins for pretibial myxoedema and test for hyper-reflexia.
• Thank the patient and clean your hands.
These findings suggest autoimmune thyrotoxicosis (Graves’ disease).
Thyroid function tests, thyroid receptor autoantibodies and thyroid scintigraphy.
Mr Birnam, 67 years old, has type 2 diabetes and presents with pain in his lower limbs.
• Introduce yourself and clean your hands.
• Inspect the skin for excessive callus, infections and ulcers.
• Palpate the feet to assess the temperature of the skin.
• Palpate the dorsalis pedis and posterior tibial pulses.
• Test for peripheral neuropathy using a 10-g monofilament and tuning fork.
• Thank the patient and clean your hands.
Doppler studies to evaluate the ankle : brachial pressure index. Review of diabetes control.
retinopathy (fundoscopy) and nephropathy (test urine for microalbuminuria).
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Common presenting symptoms 212
Female reproductive system 216
Common presenting symptoms 217
Obstetric history and examination: the booking visit 225
Drug, alcohol and smoking history 225
Routine antenatal check in later pregnancy 226
Common presenting symptoms 226
Common presenting symptoms 231
OSCE example 1: Breast examination 236
OSCE example 2: Scrotal pain history 236
The breasts are modified sweat glands. The openings of
the lactiferous ducts are on the apex of the nipple, which is
erectile tissue. The nipple is in the fourth intercostal space in
the mid-clavicular line, but accessory breast/nipple tissue may
develop anywhere down the nipple line (axilla to groin) (Figs 11.1
and 11.2). The adult breast is divided into the nipple, the areola
and four quadrants (upper outer to lower inner), with an axillary tail
(of Spence) projecting from the upper outer quadrant (Fig. 11.3).
The size and shape of the breasts are influenced by age,
hereditary factors, sexual maturity, phase of the menstrual cycle,
parity, pregnancy, lactation and nutritional state. Fat and stroma
surrounding the glandular tissue determine the size of the breast,
except during lactation, when enlargement is mostly glandular. The
breast responds to fluctuations in oestrogen and progesterone
levels. Swelling and tenderness are common in the premenstrual
phase. The glandular tissue reduces and fat increases with age,
making the breasts softer and more pendulous. Lactating breasts
are swollen and engorged with milk, and are best examined
Benign and malignant conditions of the breast cause similar
symptoms but benign changes are much more common. The
most common presenting symptoms are a breast lump, breast
pain, and skin and nipple changes. Men may present with
gynaecomastia (breast swelling). Women are often worried that
they have breast cancer, whatever breast symptom they have,
and it is important to explore these concerns.
The history of the presenting symptoms is crucial. Find out
the nature and duration of symptoms, any changes over time
and any relationship to the menstrual cycle.
Ask about risk factors for breast cancer, in particular:
• previous personal history of breast cancer
• family history of breast or ovarian cancer and the age of
• use of hormone replacement therapy
• previous mantle radiotherapy for Hodgkin’s lymphoma.
Not all patients have symptoms. Women may present with an
abnormality on screening mammography or concerns about
• Is it a single lump or multiple lumps?
Fig. 11.1 Accessory breast tissue in the axilla.
Fig. 11.2 Cross-section of the female breast.
Fractures, dislocations and trauma • 279
Establish the mechanism of injury. For example, a patient who
has fallen from a height on to their heels may have obvious
fractures of the calcaneal bones in their ankles but is also at
risk of fractures of the proximal femur, pelvis and vertebral
Use the ‘Look – feel – move’ approach. Observe patients
closely to see if they move the affected part and are able to
• See if the skin is intact. If there is a breach in the skin and
the wound communicates with the fracture, the fracture is
open or compound; otherwise it is closed.
• Look for associated bruising, deformity, swelling or wound
• Gently feel for local tenderness.
• Feel distal to the suspected fracture to establish if
sensation and pulses are present.
Fractures, dislocations and trauma
A fracture is a breach in the structural integrity of a bone. This
• normal bone from excessive force
• normal bone from repetitive load-bearing activity (stress
• bone of abnormal structure (pathological fracture, see Box
13.18) with minimal or no trauma.
The epidemiology of fractures varies geographically. There
is an epidemic of osteoporotic fractures because of increasing
elderly populations. Although any osteoporotic bone can fracture,
common sites are the distal radius (Fig. 13.47), neck of femur
(see Fig. 13.33), proximal humerus and spinal vertebrae.
Fractures resulting from road traffic accidents and falls are
decreasing because of legislative and preventive measures such
as seat belts, air bags and improved roads. A fracture may occur
in the context of severe trauma.
Fig. 13.46 Ruptured Achilles tendon. A Site of a palpable defect in the
Achilles tendon (arrow). B Thomson’s test. Failure of the foot to
plantar-flex when the calf is squeezed is pathognomonic of an acute
rupture of the Achilles tendon.
Fig. 13.47 Colles’ fracture. A Clinical appearance of a dinner-fork
deformity. B X-ray appearance.
280 • The musculoskeletal system
• Establish whether the patient can move joints distal and
• Do not move a fracture site to see if crepitus is present;
this causes additional pain and bleeding.
Describe the fracture according to Box 13.19. For each
suspected fracture, X-ray two views (at least) at perpendicular
planes of the affected bone, and include the joints above and
Fig. 13.48 Ankle deformity. A Clinical appearance. B Lateral X-ray
view showing tibiotalar fracture dislocation.
• What bone(s) is/are involved?
• Is the fracture open (compound) or closed?
• Is the fracture complete or incomplete?
• Where is the bone fractured (intra-articular/epiphysis/physis/
• What is the fracture’s configuration (transverse/oblique/spiral/
comminuted (multifragmentary)/butterfly fragment)?
• What components of deformity are present?
• Translation is the shift of the distal fragment in relation to the
proximal bone. The direction is defined by the movement of the
distal fragment, e.g. dorsal or volar, and is measured as a
• Angulation is defined by the movement of the distal fragment,
• Rotation is measured in degrees along the longitudinal axis of
the bone, e.g. for spiral fracture of the tibia or phalanges.
• Shortening: proximal migration of the distal fragment can cause
shortening in an oblique fracture. Shortening may also occur if
there has been impaction at the fracture site, e.g. a Colles’
fracture of the distal radius.
• Is there distal nerve or vascular deficit?
• What is the state of the tissues associated with the fracture (soft
tissues and joints, e.g. fracture blisters, dislocation)?
13.20 Common musculoskeletal investigations
Investigation Indication/comment
Protein Glomerular disease, e.g. SLE, vasculitis
Secondary amyloid in RA and other chronic arthropathies
Drug adverse effects, e.g. myocrisin, penicillamine
Blood Glomerular disease, e.g. SLE, vasculitis
Full blood count Anaemia in inflammatory arthritis, blood loss after trauma
Neutrophilia in sepsis and very acute inflammation, e.g. acute gout
Leucopenia in SLE, Felty’s syndrome and adverse effects of antirheumatic drug therapy
Erythrocyte sedimentation rate/plasma viscosity Non-specific indicator of inflammation or sepsis
C-reactive protein Acute-phase protein
Urea and creatinine ↑ in renal impairment, e.g. secondary amyloid in RA or adverse drug effect
Uric acid May be ↑ in gout. Levels may be normal during an acute attack
Calcium ↓ in osteomalacia; normal in osteoporosis
Alkaline phosphatase ↑ in Paget’s disease, metastases, osteomalacia and immediately after fractures
Angiotensin-converting enzyme ↑ in sarcoidosis
Urinary albumin : creatinine ratio Glomerular disease, e.g. vasculitis, SLE
in up to 15% of normal population. Superseded by anti-cyclic citrullinated peptide antibodies
RA. Occasionally found in Sjögren’s syndrome
Anti-Ro, Anti-La Sjögren’s syndrome
Common investigations in patients with musculoskeletal disease
13.20 Common musculoskeletal investigations – cont’d
Investigation Indication/comment
Anti-ribonucleoprotein Mixed connective tissue disease
Schirmer tear test, salivary flow test Keratoconjunctivitis sicca (dry eyes), Sjögren’s syndrome
bone changes in Paget’s disease, pseudofractures (Looser’s zones) in osteomalacia
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