STATION 1

REST
INSTRUCTIONS TO CANDIDATE:
Examination station
You are an intern on a general medicine unit. A patient with long-standing, poorly controlled,
type 2 diabetes mellitus has been admitted to your ward with complications of this condition.
Conduct a physical examination of the patients lower limbs directed at eliciting any
complications of diabetes. As you go, explain to the examiner for each specific component of
the examination:
A.
B.
C.
D.

Explain what you are doing

Demonstrate the examination technique
Describe what you found on examination
Explain the reason for each aspect of the examination

All relevant equipment is supplied.

Discussion with the patient can be limited to briefly introducing yourself and
explaining what you will be doing to gain their cooperation in the examination.
However no history taking is required to fulfil the requirements of this station.
This station will take 9 minutes. To save time, after you have adequately demonstrated each
aspect of the examination, the examiner may interrupt to hear your findings and reasons and
ask you to move on to the next aspect of examination.

INSTRUCTIONS FOR CLINICAL TRAINING ASSOCIATES

Introduction and History At this station you will be a patient who has been admitted to the
ward for complications of your diabetes. This is all that the student will know on entering the
room. This station is a physical examination station, so you will spend the whole time lying on
a couch. You will need to expose most of your lower legs and so should wear loose shorts. If
the students ask you about your diabetes, say that you take tablets for it three times per day,
but you can't remember the name of them. If they ask you any other questions, simply say
you are not sure or don't know. The examiner will remind them that questions should be
restricted to what is necessary to conduct the examination.
How to Portray Physical Signs You should look relaxed and be cooperative, however if the
student's examination technique is painful, you should tell them (remember you have to
survive multiple examinations!). The problems you have include:

reduced feeling in all your toes and forefeet, but not at or above the ankles
reduced ability to detect movement in your toes, but not in the ankles, knees or hips
reduced ability to feel vibration in your ankles, feet and toes, but not above the ankles
To find these problems, the student may do the following things to you with your eyes closed.
These require you to respond in the way indicated:

Gently stroke your legs and feet with their hand or some cotton wool, while asking if you
can feel them
You should not respond to gentle stroking of the toes and forefeet, but should admit to
feeling heavier stroking or pressure. If they ask you what heavier stroking or pressure
feels like, say it is as if you still have some socks on.
Move your big toes up and down several times, asking you to tell them which direction
they are moving them. They may also hold them still and ask you for a direction of
movement to trick you. Your response should be "I don't know". The student should hold
your toe by its sides to get this response from you. If the student grabs your toe above and
below or moves it forcefully your responses should be exactly what you feel (hopefully
correct!), as this makes it too easy to feel what is going on.

Hold your ankle and move your whole foot up and down, asking you to tell them which
direction they are moving them. With this examination, your responses should be exactly
what you feel (hopefully correct!), as this is an easier test for someone with diabetes.

Check your ability to detect vibration by pressing a tuning fork against various bony areas
in your feet, ankles, shins, knees and pelvis and asking you if you feel vibration or just
pressure. The student may make the tuning fork vibrate or may stop it vibrating prior to
pressing it on your bones. They may also ask you to say when it stops vibrating As you
have lost vibration sense in your feet and ankles only, your responses should come from
the following table:
Site
Feet and ankles
Shins, knees and pelvis

What you feel

Vibration
Pressure
Vibration
Pressure

What you say

Pressure
Pressure
Vibration
Pressure

The students may also do the following things, which do not require you to respond in any
special way:

Check your skin, especially on your feet and ankles

Check your pulses in your feet, behind your knees and in your groins
Feel for the temperature in your legs
Squeeze your toes to check for the return of blood flow on releasing them
Test the reflexes in your knees and ankles using a tendon hammer

NOTES TO EXAMINERS - Examination of Diabetic Patient

After checking the student's details, remind them of the tasks at this station as follows:
"Conduct a physical examination of this patients lower limbs directed at eliciting any
complications of diabetes. For each specific component of the examination , as you go,:
A. Explain to me what you are doing
B. Demonstrate the examination technique
C. Describe what you found on examination
D. Explain to me the reason for each aspect of the examination
You have nine minutes."
Marking
The marksheet is designed to award half a mark for each box that is ticked. Leaving boxes
unmarked implies that the point was not done or done incorrectly. You do not need to add
up the marks after each student - this can be done after the exam.
Time Management
Please note that, although this is a double station lasting nine minutes, there is a lot for
students to do and they may run overtime. To avoid this:
when students have elicited a sign satisfactorily, tell them that they have done enough
and ask them to explain their findings and their reasons for seeking that sign. For
example, with testing of vibration sense, as soon as they have completed testing one
leg and have commenced on the other leg, they can be stopped and asked to present
their findings on the first leg. However, if they feel they need to examine both sides for
comparison before commenting on the signs, they should be allowed to do so.
if students seek signs not listed on the marksheet, tell them that this is not necessary
today and to move on to the next sign. This particularly applies to testing sensation with
a pin and checking femoral pulses, tests which may be difficult for the clinical training
associates.
discourage history taking. Discussion with the patient should be limited to what is
necessary to elicit the signs.
If students finish early and have omitted one or more components of examination, ask them
if there is anything more they would like to examine. If they cannot think of anything more
to do, you may then suggest a component of examination from the marksheet, but they
should not get the mark for this in the first column on the marksheet. They can, however,
get marks for technique, findings and reasons for examination.
It is important to explain to students as they commence examination of reflexes, that they
should strike each tendon no more than three times. If they wish to retest absent reflexes
using reinforcement, they may have another three strikes. These guidelines are to avoid
damage to roleplaying patient's tendons over the course of the examination. If patients are
getting sore tendons, you may call for a reserve patient during a break.

Equipment Required
Tendon hammer, Cotton wool, 128 Hz tuning fork

A patient with well established diabetes mellitus is admitted to your ward with complications of her condition.
Conduct a physical examination of the patients lower limbs. As you go:
A. Explain what you are B. Demonstrate the
C. Describe what
D. Explain the reason for each
doing
technique
you found on
aspect of the examination
examination

This station will take 9 minutes.

Aspect of examination

Skin changes

Technique

Found expected
findings

Explain reason for specific element of

examination

All normal

All pulses normal

Evidence of peripheral vascular disease

Normal

Evidence of impaired microcirculation

Normal

Evidence of peripheral neuropathy

Examines:
All sides of feet and
ankles
Between toes

Evidence of poor circulation

Trophic changes (shiny skin, lack of body
hair)
Ischaemia / gangrene of extremities
Ulceration
Tinea or other infections
Pressure areas eg calluses

Examination of vascular system

Dorsalis pedis pulses

Posterior tibial pulses

Limb temperature

Identifies correct
sites for all pulses
Uses back of hand
to check temperature

Examination of capillary
return

Examination of peripheral nervous system

Light touch

Proprioception

Vibration

Tests ankle jerks

Tests knee jerks

General

Extra mark for

use of light touch
instrument
Extra mark for
good technique (holds
toe by side)
Checks bony
protuberance on feet and
ankles
Checks knee/patella
or ASIS
Supports limb well

Reduced light
touch in all toes and
distal feet
Reduced
bilaterally only

Reduced at feet
and ankles
Normal at knee
and ASIS
Normal ankle
jerks
Normal knee
jerks
Briefly explains to patient what is to be done
Well ordered system of examination overall

Scoring - each point earns mark

Maximum marks = 19. Minimum marks to pass = 12

Examiners: further remarks may be made on the back of this sheet. If you do so please indicate here .
PLEASE TICK THE APPROPRIATE BOX: Note: These marks will not be included in the students score this year.
1. Very poor
2. Marginal fail
3. Pass
4. Above average
Made the sort of errors or omissions that
Omitted some of
Better than 3, but
Sound, but with some
could lead to serious problems eg miss
the key aspects
was not strong in one
aspects that were not
major diagnosis, cause patient to be
despite significant
or more of the
optimal. May have
upset, cause patients harm, unethical or
prompting by the
qualities described in 5
required some prompting
unprofessional behaviour
examiner, poor
but responded
technique
appropriately

5. Outstanding
Covered all essential aspects
competently, clearly, confidently,
logically and sensitively. Did not
require any prompts from the
examiner to direct the interview /
examination.