Medicines Prep

Diabetic Foot Exam

  1. Diabetic Foot Exam
    1. Introduction
    2. Inspect
    3. Palpate
    4. Auscultation
    5. Sensation
    6. Vibration
    7. Proprioception
  2. Anki Deck

Introduction

A safe and effective clinical examination always begins with taking a structured patient history. In an OSCE you may be presented with medical tools only, this is a knows how OSCE, you can simply state how you would do the exam, mentioning the history, otherwise, follow the guide for a real patient.

1. Perform Hand Hygiene & Apply Appropriate PPE

Before any physical contact, ensure proper handwashing technique and wear the correct personal protective equipment (PPE). This step protects both the patient and the clinician, and is a core requirement in all OSCEs and real‑world clinical settings.

2. Explain the Procedure & Obtain Valid Consent

Always communicate clearly with the patient. Explain what you plan to do, why it’s necessary, and what they should expect. Confirm that the patient understands and gives informed consent before proceeding.

Inspect

Inspect the Patient’s Feet Thoroughly

A high‑quality lower‑limb assessment begins with a structured visual inspection. This helps identify early signs of biomechanical issues, diabetic complications, and vascular disease.

Begin “externally”:

  • Shoe size
    Ill‑fitting shoes can cause pressure points, calluses, and ulceration
  • Wear on the soles
    Uneven wear patterns may indicate chronic gait abnormalities
  • Observe the patient’s gait, noting:
    • Feet turning inward
    • Walking speed
    • Asymmetrical footing

Ask About Pain Using SOCRATES

Before progressing, explore whether the patient experiences pain, discomfort, numbness, or functional limitations.

Inspect the Lower Limbs Carefully

A complete lower‑limb inspection focuses on colour, vascular health, skin integrity, and structural abnormalities.

What to Assess:

  • Colour changes
    • Bluish discolouration may indicate poor peripheral blood supply
    • Hair loss can accompany chronic poor perfusion
  • Ulcers
    • Common in diabetic patients
    • Often slow to heal and may leave visible scars from previous episodes
  • Gangrene
    • A severe complication of diabetes and vascular disease
    • Requires urgent medical attention and is a major OSCE red flag
  • Missing limbs
    • May result from gangrene or critical ischemia
    • Highlights the importance of early detection and prevention

A frequently missed step scoring higher marks is to check between the patient’s toes

Palpate

Palpation of the Feet and Lower Limbs

A high‑quality vascular and neurological assessment requires precise palpation. This step helps identify poor perfusion, deep vein thrombosis, and early signs of diabetic complications.

1. Assess the Temperature of the Feet

Use the back of your hand to compare temperature between both feet. Temperature differences can reveal important vascular clues.

Clinical Indicators:

  • Cold feet may suggest poor peripheral perfusion
  • Always consider contextual factors – for example, if the patient was wearing open footwear on a cold day

2. Palpate Key Peripheral Pulses

A thorough lower‑limb examination includes palpating the:

  • Posterior tibial
  • Dorsalis pedis

What to Assess:

  • Presence of pulses – Are they palpable on both sides
  • Strength of pulses – Compare right vs. left for symmetry
  • Quality of perfusion – Weak or absent pulses may indicate arterial insufficiency

3. Characterise the Pulse Accurately

Once the pulses are identified, assess their characteristics to build a complete vascular picture.

Pulse Characteristics to Document:

  • Rate – For example, 80 BPM
  • Rhythm – Such as regularly regular
  • Character – Weak, strong, bounding, or thready

These descriptors help differentiate between normal vascular function and potential pathology.

Auscultation

Auscultation When Pulses Cannot Be Palpated Manually

When peripheral pulses are difficult to palpate, auscultation with a Doppler device becomes essential. This technique is widely used in vascular assessments, diabetic foot checks, and OSCE stations focused on peripheral arterial disease.

Use a Doppler Device to Assess Key Arterial Pulses

The Doppler allows you to detect blood flow in arteries that may be weak, deep, or compromised.

1. Arteries to Assess:

  • Tibial pulse
  • Dorsalis pedis

These two sites are critical for evaluating lower‑limb perfusion and identifying early signs of vascular insufficiency.

2. Apply Ultrasound Gel for Clearer Sound Transmission

Ultrasound gel reduces air interference and improves the clarity of the Doppler signal. A small amount is enough to enhance sound conduction and ensure accurate interpretation.

3. Position the Probe Correctly

For optimal detection, position the Doppler probe at a 45‑degree angle over the artery. This angle maximises the reflection of sound waves and produces a clearer, more reliable signal.

Sensation

What Is a Monofilament Sensation Test?

A monofilament test is a quick, painless assessment used to check sensation in the feet; especially important for patients at risk of neuropathy.

1. Reassurance and Demonstration

Before the assessment begins, the clinician gently demonstrates the sensation of the monofilament on the patient’s arm.

2. Monofilament Points to Remember:

  • 10g of force is applied
  • Should be help for 1 – 2 seconds

3. Testing Protective Sensation

Once the patient is comfortable, they are asked to close their eyes so the clinician can accurately assess true sensation response. The monofilament is bent at the:

  • Pulp of the hallux
  • Pulp of the 3rd digit
  • 1st, 3rd, and 5th metatarsophalangeal joints

4. Ensuring Accuracy and Patient Safety

To maintain the integrity of the assessment, clinicians may occasionally include a non‑contact trial. This is not seen in an OSCE, but may be used in practice to prove a patient-centred approach.

Vibration

What Is a Vibration Sensation Test

A vibration test is a neurological assessment used to check how well the nerves in the feet are functioning. It’s especially important for patients at risk of peripheral neuropathy and diabetes‑related nerve damage.

1. The 128Hz Tuning Fork

Clinicians use a 128Hz tuning fork, the gold‑standard frequency for assessing vibration sense. This frequency is specifically chosen because it reliably stimulates large‑fibre peripheral nerves.

2. Establishing Baseline Sensation

Before testing the feet, the clinician gently places the vibrating tuning fork on a bony landmark, such as the sternum.

  • This confirms that the patient recognises the sensation of vibration.
  • It also helps build trust and reduces anxiety before moving to more sensitive areas.

3. Testing the Interphalangeal Joint

Once the patient is comfortable, they are asked to close their eyes and simply say when they:

  • Feel the vibration begin
  • Notice the vibration stop

The clinician then places the vibrating 128Hz tuning fork on the interphalangeal joint of the hallux as a test point

4. Mapping Sensory Changes Along the Foot

If sensation is reduced at the big toe, the clinician continues testing more proximal joints, moving gradually up the foot.

This helps determine:

  • How far the impairment extends
  • Whether the sensory loss is mild, moderate, or advanced
  • Which nerves may be affected

Proprioception

What Is a Proprioception Test?

Proprioception refers to the body’s ability to sense the position and movement of joints without needing to look. Testing proprioception in the feet is a key part of neurological assessment, especially for patients at risk of sensory loss or balance problems.

1. Demonstrating the Movement

To begin, hold the distal phalanx of the big toe by its sides, never from above or below, to avoid giving tactile clues.
The toe is then moved upwards and downwards while the patient watches.

  • The clinician clearly verbalises:
    • “This is up.”
    • “This is down.”

This helps the patient understand the movements before the actual assessment begins.

2. Testing With Eyes Closed

Once the patient is comfortable, they are asked to close their eyes.
This removes visual cues and allows the clinician to accurately assess true joint‑position sense.

3. Randomised Movement Testing

The clinician then moves the big toe up and down in a random sequence, usually 3–4 times. The patient is asked to identify the final position by saying whether the toe is pointing up or down.

4. Assessing More Proximal Joints if Needed

If the patient struggles to correctly identify the direction of movement, continue the assessment further up the limb, testing more proximal joints.

This helps determine:

  • The level of sensory impairment
  • Whether the deficit is localised or more widespread
  • How significantly proprioception may be affected

This structured approach ensures a clear, clinically meaningful understanding of the patient’s neurological function.

Anki Deck

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