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.

A B

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

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OSCE example 1: Neck swelling

Miss Duncan, 27 years old, presents with a 6-month history of palpitations, weight loss and neck swelling.

Please examine her thyroid status

• Introduce yourself and clean your hands.

• Carry out a general inspection, observing dress, body habitus, agitation, restlessness, diaphoresis, anxiety, exophthalmos, goitre and neck scars.

• Inspect the hands for vitiligo, palmar erythema, thyroid acropachy and fine tremor (hands outstretched with paper over the dorsum).

• Palpate the pulse for bounding pulse, tachycardia and atrial fibrillation.

• Inspect the eyes for lid retraction (scleral show) and exophthalmos (look down from above and behind the patient).

• Test eye movements for ophthalmoplegia and lid lag.

• Examine the neck for scars, goitre, lymphadenopathy. Ask the patient to swallow to see the thyroid gland rise on swallowing.

• Palpate the thyroid (again on swallowing) and cervical lymph nodes; percuss manubrium for retrosternal goitre.

• Auscultate any goitre for bruit.

• Assess the patient for proximal myopathy (ask them to stand from sitting, with their arms crossed).

• Examine the shins for pretibial myxoedema and test for hyper-reflexia.

• Thank the patient and clean your hands.

Summarise your findings

The patient is thin, with a fine tremor, tachycardia, exophthalmos and lid lag. In the neck there is a smooth, non-tender goitre.

Suggest a diagnosis

These findings suggest autoimmune thyrotoxicosis (Graves’ disease).

Suggest investigations

Thyroid function tests, thyroid receptor autoantibodies and thyroid scintigraphy.

Advanced level comments

Thyrotoxicosis may cause an elevated alkaline phosphatase and hypercalcaemia due to increased bone turnover and a normochromic normocytic

anaemia.

OSCE example 2: Diabetic feet

Mr Birnam, 67 years old, has type 2 diabetes and presents with pain in his lower limbs.

Please examine his feet

• Introduce yourself and clean your hands.

• Carry out a general inspection of the lower limbs, looking for hair loss, nail dystrophy or discoloration.

• Inspect the skin for excessive callus, infections and ulcers.

• Inspect the joints. Ask the patient to stand so that you can assess the foot arch and look for deformation of the joints of the feet.

• 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.

Summarise your findings

The patient has pale, cool feet with absent dorsalis pedis pulses bilaterally. The skin is intact but there is loss of sensation in a stocking distribution in

both feet.

Suggest a diagnosis

The most likely diagnosis is peripheral vascular disease and peripheral neuropathy secondary to diabetes.

Suggest investigations

Doppler studies to evaluate the ankle : brachial pressure index. Review of diabetes control.

Advanced level comments

With peripheral neuropathy, also take an alcohol history and check vitamin B12 levels to take other common causes of peripheral sensory loss into

account. Peripheral neuropathy can be confirmed on nerve conduction studies. Offer an examination for other microvascular complications, such as

retinopathy (fundoscopy) and nephropathy (test urine for microalbuminuria).

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