Chapter 14Diabetes Examination

• Type 1 or Type 2 Diabetes? Do you use insulin? Age at diagnosis? How was patient diagnosed (e.g. hospitalized with Diabetic Ketoacidosis, Screening with HbA1c, Fasting blood glucose, or oral glucose tolerance test during pregnancy)?

• Tracking Sugars: Do you keep track of your sugars?
  • When & how often do you check them?
  • Do your sugars tend to be high or low (ask if patient can share specific values from logbook of measurements)? When and how often are they high or low?
  • Do you use a continuous glucose monitoring (CGM) device? – can look at reports on device
• High Sugar Level Symptoms: Excessive thirst (Polydipsia), polyuria, polyphagia, altered level of consciousness (aLOC), DKA, Hyperosmolar Hyperglycemic Syndrome (HHS)
• Low Sugar Level Symptoms: Shakiness, dizziness, sweating, hunger, palpitations, seizures?
  • Are you able to manage lows by yourself?
• Patient education: Advise patient to check sugars before driving and to avoid driving if hypoglycemic (re: seizures); keep snacks in car to treat hypoglycemia.

• Medications: Do you require insulin? Do you sometimes miss your medications or insulin?
• Diet: Are you keeping a balanced diet? Do you avoid excess sugars? Are you incorporating different food groups into your diet?
• Exercise: Frequency per week? What does a workout look like? Recent activity level changes?
• Recommendation: 150 mins moderate-to vigorous-intensity aerobic physical activity/week (e.g. 30 mins 5x/wk in bouts of 10 minutes or more) & resistance exercises (e.g. lifting weights) 2 days/week – explored in Ch 38 – Motivational Interviewing and Lifestyle Interventions – Integration Foundation)

• Neuropathy:
  • Peripheral Neuropathy: Loss of sensation, paresthesia (pins/needles), or heaviness in extremities? Feels like walking on foam, or unable to feel roughness of the ground? Weakness in legs when climbing stairs?
  • Autonomic Neuropathy: Do you feel lightheaded on standing up quickly? Difficulty starting to urinate, or lose control of bladder function? Sweat abundantly from face only?
  • Gastroparesis (delayed gastric emptying): nausea/vomiting, bloating, early satiety, upper abdominal pain?
• Retinopathy: Any new changes to your vision? Are you being followed by an ophthalmologist? (recommend yearly screening for Type 1 Diabetes, q1-2 years for Type 2 Diabetes)
• Nephropathy: Are you seeing a nephrologist? Any frothy urine (proteinuria re: nephrotic syndrome)? On dialysis? (recommend annual Urine ACR, albumin-to-creatinine ratio screening)

• Coronary Artery Disease: Any angina? Previous Myocardial Infarction (MI)?
• Cerebrovascular: One-sided weakness? TIA (Transient Ischemic Attack)? Stroke?
• Peripheral Vascular (See Chapter 8 – Peripheral Vascular Exam – MF1): Claudication (Pain or cramping in legs on exertion, relieved by rest within 10 minutes)? Rest pain (Red flag – pain at rest, worsens with reclining, improves with hanging feet off of bed or standing)? Sexual dysfunction?

• Have you noticed any new wounds, ulcers, infections, pain or redness in your legs or feet?
• Do you have decreased sensation or paresthesia (pins/needles) in your feet?
• Any recent trauma to the feet that you might remember?
• Self-Care: Hygiene – Do you check your feet for ulcers and sensation changes regularly?
• Recommendations: Advise patient to check feet and legs every day; care for nails regularly; wear properly wearing footwear; test bath/shower water with hand before stepping in to ensure water is not too hot.

• Diabetes Emergencies: Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic Syndrome (HHS), hospitalizations
• Macrovascular Complications: Coronary Artery Disease, Cerebrovascular Disease, Peripheral Vascular Disease
  • Cardiovascular Disease: Angina, MI, Heart Failure, Hypertension,
  • Cerebrovascular Disease: Stroke, TIA
  • Peripheral Vascular Disease: Intermittent claudication; Rest Pain (Red Flag – described above)
    • Acute Limb Ischemia (<2 wks): Acute severe hypoperfusion of a limb due to arterial occlusion; causes include arterial thrombus, embolism or dissection. Characterized by 6 Ps (Pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia i.e. cold). Limb threatening ischemia particularly concerning if there is sensory or motor loss.
    • Critical Limb Ischemia (≥ 2 wks): Limb-threatening arterial occlusion, characterized by ischemic rest pain, non-healing wound/ulcers, or gangrene in 1 or both legs.
• Microvascular Complications: Neuropathy, Retinopathy, Nephropathy
  • Neuropathy: Peripheral neuropathy, Autonomic Neuropathy, Gastroparesis
  • Chronic Kidney Disease: Nephrotic Syndrome, Nephritic Syndrome; End-Stage Renal Disease (e.g. Dialysis, Transplant)
• Metabolic Syndrome (Central Obesity, HTN, ↑ Serum Triglycerides, ↓ Serum HDL, & Diabetes – ↑ risk for CVD)
• Autoimmune Diseases (Re: T1DM): especially Autoimmune Thyroid Diseases (e.g. Hashimoto’s thyroiditis, Grave’s disease), Celiac Disease, Autoimmune Gastritis/Pernicious Anemia, Vitiligo
• Recent Infections: UTI (↑ susceptibility), Foot/Ulcer Infections, Wound Infections
• Chronic Pancreatitis, Pancreatic Cancer: Can present with Pancreatogenic (Type 3c) Diabetes due to progressive pancreatic endocrine functional impairment.

• Heart Disease: Coronary Artery Bypass Grafting (CABG), Percutaneous Coronary Intervention (PCI) + Stenting
• Islet Cell Transplantation (for Type 1 Diabetes)
• Pancreatectomy, WHIPPLE Procedure (e.g. for Pancreatic Cancer) – can cause Type 3c (Pancreatogenic) Diabetes

• Coronary Artery Disease, Diabetes Mellitus (T2DM stronger genetic linkage than T1DM), Cerebrovascular Accidents

• Alcohol Intake; Smoking; Substance Use; Exercise; Diet
• Finances and Supports: Do you have trouble making ends meet? What are your living arrangements? Next of kin?
  • Do you sometimes have trouble affording your diabetes medications or insulin?
  • Why Ask: Diabetes as a chronic illness is costly (e.g. testing strips, oral medications, insulin). Barriers to adequate glycemic control can lead to worsening of diabetes complications, as well as diabetes emergencies like DKA/HHS.

• How long have you been taking each medication? What dosing? Any recent dose changes?
• Antihyperglycemic Agents:
  • Biguanide: Metformin (1st line for Type 2 Diabetes)
  • Glucagon-Like Peptide 1 Receptor Agonist (GLP1-RA): Exenatide; Liraglutide, Semaglutide
  • Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor: Canagliflozin, Dapagliflozin, Empagliflozin
  • Dipeptidyl-Peptidase 4 (DPP4) inhibitor: Linagliptin, Sitagliptin, Saxagliptin (saxagliptin specifically ↑ risk of Heart failure)
  • Others
    • Alpha-Glucosidase Inhibitor: e.g. Acarbose
    • Sulfonylureas: e.g. Gliclazide, Glyburide → risk of hypoglycemia
    • Thiazolidinedione: e.g. Pioglitazone → risk of weight gain
    • Meglitinides: e.g. Repaglinide → risk of hypoglycemia
• Insulin: Common regimen to see is Basal Bolus Insulin Therapy (BBIT) – combination of Rapid- or Short-Acting (as bolus insulin) and Long-Acting (as basal insulin)
  • Formulations: Rapid Acting (e.g. Aspart, Lispro, Glulisine); Short Acting (e.g. Regular); Intermediate-Acting (e.g. NPH); Long-Acting (e.g. Detemir, Glargine, Degludec)
  • Insulin Pump: May be seen in patients particularly with Type 1 Diabetes
  • Insulin is associated with risk of hypoglycemia and weight gain.
• Note on GLP1-RA and SGLT2 inhibitors: Recommended in patients with CAD, CKD or HF with established cardiorenal benefits. SGLT2 inhibitors are also part of Guideline-Directed Medical Therapy (GDMT) for Heart Failure with Reduced Ejection Fraction (HFrEF) and reduce hospitalizations in Heart Failure with Preserved Ejection Fraction (HFpEF) and progression of Chronic Kidney Disease (CKD).
• Note: Canadian Diabetes Association (CDA) has a useful tool for T2DM medication regimens tailored to your patient – search Pharmacotherapy for Type 2 Diabetes

• Steroids, statins, ACE inhibitors, diuretics, etc.
• Painful Peripheral Neuropathy Tx: Anticonvulsants (e.g. Pregabalin, Gabapentin); Capsaicin cream; Antidepressants (TCAs e.g. Amitriptyline, Nortriptyline; SNRI e.g. Duloxetine, Venlafaxine)

• If a patient with diabetes is ill, unable to maintain fluid intake or has an acute kidney injury, they should hold medications from the following classes: SADMAN
  • Sulfonylureas – ↓ clearance and risk of adverse effects
  • ACE-inhibitors – risk of Acute Kidney Injury (AKI)
  • Diuretics/Direct Renin-inhibitors – risk of AKI
  • Metformin – ↓ clearance and risk of adverse effects
  • ARBs – risk of AKI
  • NSAIDs – risk of AKI
  • SGLT2-inhibitors – risk of AKI

• Do you miss doses of your medications or insulin (re: glycemic control, hospitalization)?
  • Any barriers to management (e.g. affordability)?

• Blood Pressure – Target Systolic BP <130 mmHg, Diastolic BP <80 mmHg
• Be sure to do Orthostatic Vitals as well (re Autonomic neuropathy complication)

(Also seen in Ch 4 – Vital Signs – MF1)

AFMC level Pre-clerkship 4 · Clerkship 4

Say: Would it be alright if we measure your height, weight, hip circumference and waist circumference today?

Set-Up: Ask permission before weighing someone, and never weigh a patient in front of others. Weighing scales should be placed in private areas in clinical spaces.

Do:

7. Ask patient to remove shoes.
8. Requires a weight scale, a method of measuring height, and a tape measure.
9. Measure the patient’s weight and height using appropriate scales.
10. For waist circumference, measure circumference at a level midway between the Iliac Crest and last palpable rib (WHO guidelines)
11. For hip circumference, measure at the level with the widest portion of the buttocks.
12. Using these measurements, calculate BMI (kg /m²), Waist-Height Ratio, and Waist-Hip Ratio.

Report: The height and weight we measured today were _____, with a BMI of ______.

Why Check: Waist-Height Ratio and Waist-Hip ratio are objective measures of central (abdominal) obesity associated with ↑ cardiovascular risk. These calculated measures, including BMI, are imperfect, but clinically useful to monitor individual patients over time. Differential diagnoses for weight changes include Nutritional state, malignancy, chronic illness, eating disorders, hyper/hypothyroidism, hyper/hypo-cortisolism, etc.

WHO Classification of Weight Status:

Edmonton Obesity Staging System (EOSS)²: Staging according to obesity-related risk factors, physical symptoms, psychological symptoms, and functional impairment. Overall stage determined by highest component (e.g. pt with Stage 3 Physical Symptoms, Stage 1 otherwise is considered EOSS Stage 3 Overall)

• Stage 0
  • Obesity-Related Risk Factors: None
  • Physical Symptoms: None
  • Psychological Symptoms: None
  • Functional Impairment: None
• Stage 1
  • Obesity-Related Risk Factors: Subclinical Risk Factors (Borderline HTN, Impaired fasting glucose, elevated liver enzymes, etc.)
  • Physical Symptoms: Mild Not Requiring Medical Intervention (e.g. moderate exertional dyspnea; occasional aches/ pains; fatigue)
  • Psychological Symptoms: Mild
  • Functional Impairment: Mild (Quality of Life not impacted)
• Stage 2
  • Obesity-Related Risk Factors / Physical Symptoms: Obesity-Related Comorbidities Requiring Medical Intervention (HTN, T2DM, OSA, PCOS, OA, GERD)
  • Psychological Symptoms: Moderate (e.g. Depression, Eating D/O, Anxiety D/O)
  • Functional Impairment: Moderate (QoL beginning to be impacted)
• Stage 3
  • Obesity-Related Risk Factors / Physical Symptoms: Significant Obesity-Related End-Organ Damage (MI, HF, Diabetes Complications, Incapacitating OA)
  • Psychological Symptoms: Significant (e.g. Depression, Suicidal Ideation)
  • Functional Impairment: Significant (QoL significantly impacted)
• Stage 4
  • Obesity-Related Risk Factors / Physical Symptoms: Severe (Potentially End-Stage) Obesity-Related End-Organ Damage
  • Psychological Symptoms: Severe disabling psych. symptoms
  • Functional Impairment: Severe functional limitations

Modification for Patients with Limited Mobility:

• Height: Can be measured using the demi-span (distance from mid-sternal notch to the end of the middle finger in the coronal plane) and then calculated with the following formulas:
  • For female patients: Height (cm) = (1.35 x Demi-span) + 60.1
  • For male patients: Height (cm) = (1.40 x Demi-span) + 57.8
• Weight: A patient’s estimate of their own weight is more accurate vs. physician’s. If the patient is unable to give an estimation, body weight can be estimated using body height, and hip and waist circumference.

Modification for Patients who are Transgender:

• Transmasculine Patients (FTM): Patients on masculinizing hormone therapy may have body fat redistribution and/or increased muscle mass.
• Transfeminine Patients (MTF): Patients on feminizing hormone therapy may have body fat redistribution and/or decreased muscle pass.

(Also seen in Ch 7 – Head and Neck Exam – MF1; Ch 31 – Screening Neuro Exam – MF4; and Ch 40 – Ophthalmology Exam – IF)

AFMC level Pre-clerkship 2 · Clerkship 3

Say: I will now inspect each eye using a direct ophthalmoscope. You will feel my hand touch the shoulder to keep the ophthalmoscope steady. Please look at an object on the wall in the distance at your eye level (preventing constriction due to pupillary accommodation reflex)

Setup: Room should still be dim. Stand facing the patient; if you’re examining the patient’s right eye first, use your right eye to look (vice versa). Adjust the scope’s focus (if you’re not wearing your nearsighted prescription glasses, may take more adjusting) by focusing on an object in room. Use low-moderate light intensity typically with medium aperture.

Do: Steady your hand on their shoulder. Shine the light from ophthalmoscope in patient’s eye; should see the red reflex. Follow reflex and slowly move toward patient. Find an artery and follow that towards the centre. You should come upon the optic disc (head of optic nerve, a confluence of retinal nerve fibers exiting the globe) and the optic cup (white centre of optic disc). Look for signs of optic disc swelling, and loss of venous pulsations. Follow the Superonasal Arcade, Inferonasal Arcade, Superotemporal Arcade, and Inferotemporal Arcade. Focus on Macula (temporal to optic disc), which contains Fovea where you can see a Yellow Reflex in healthy people. Look for signs of hemorrhages, neovascularization (small branching vessels) and cotton wool spots (fluffy white patches).

Report: The optic disc was visualized in each eye, with no signs of optic disc swelling, neovascularization or loss of venous pulsations.

Why Check: Direct fundoscopy allows for a focused exam of intraocular structures, alongside external examination and the slit lamp examination (explored in Ch 40 – Ophtho Exam – IF). Fundoscopy also forms a part of the screening neurological examination (See Chapter 31 –Neuro Exam – MF4). Major pathologies to look for include:

• Absent Red Reflex: Can be due to cataracts, retinoblastoma, retinal detachment, vitreous hemorrhage, etc.
• Glaucoma (Chronic): Enlarged cup/disc ratio >0.5 (normal cup-to-disc ratio ≤0.5)
• Papilledema: Swollen optic disc with no clear demarcated disc border due to ↑ Intracranial Pressure, coupled with loss of venous pulsations. Particularly important to assess for in patients with new onset headaches.
• Retinal Detachment/Tear/Break: Can occur inside field of view on direct ophthalmoscopy.
• Cotton Wool Spots: Sign of vascular insufficiency or ischemia to an area of retina – most common causes being hypertensive and diabetic retinopathy (Ch 14 – Diabetes Exam – MF3)
• Hypertensive Changes: Arteriolar spasm, exudates, flame-shaped hemorrhages, loss of venous pulsations, ghost vessels, cotton wool spots.
• Diabetic Retinopathy: Cotton wool spots, dot and blot hemorrhages, neo-vascularisations

(Also seen in Ch 8 – Peripheral Vascular Exam – MF1)

AFMC level Pre-clerkship 1 · Clerkship 2

Why Check: Differentiates peripheral arterial vs. peripheral venous disease – Checking for macrovascular complications of diabetes

Say: I will inspect the neck, armpits, navel and forehead, as well as the lower legs to look for skin changes.

Setup: Be sure to drape patient appropriately for the areas to be examined

Do: Assess for Acanthosis nigricans (hyperpigmentation of skin typically found in body folds), as well as evidence of Impaired Healing (re longstanding cuts and bruises)

Report: I note no Acanthosis nigricans or impaired healing.

Acanthosis Nigricans³⁴

Why Check: Characteristic skin changes in diabetes complications

Say: I will now inspect the mouth for thrush or ulcers. Can you open the mouth wide?

Do: Look for Thrush (white velvety plaques that can scrape off) on tongue and in mouth) and for Ulcerations.

Report: I note no evidence of oral thrush or ulcerations.

Oral Candidiasis⁵

Why Check: Thrush is important to detect, and is common in patients with diabetes mellitus and who are immunosuppressed e.g. on glucocorticoid medication; Ulcerations evidence of peripheral vascular disease

See Chapter 8 – Peripheral Vascular Exam – MF1 – Temperature, cap refill, pitting edema, paralysis, pulses

Why Check: Macrovascular complications of Diabetes

See Chapter 5 – Respiratory Exam – MF1 – auscultate lung fields for crackles or wheezes

Why Check: Looking to see signs of respiratory infections

See Chapter 6 – Cardiac & Heme Exam – MF1 - looking for extra heart sounds or murmurs

Why Check: Diabetes is a part of the Framingham risk score; therefore, you should conduct a cardiac examination as part of the diabetes examination

See Chapter 8 – Peripheral Vascular Exam – MF1 – auscultation of bruits

Why Check: Macrovascular complications of Diabetes

See Chapter 13 – Abdominal Exam – MF3 – looking for general appearance

Why Check: General scanning examination

Say: I will now inspect the feet for any wounds, ulcers or infection.

Do: Look for any ulceration/wounds on the feet. If present, comment on location, size, depth, infection or discharge, surrounding erythema/ swelling/fluctuance or cellulitis, and visible bone. Wounds can be classified according to the University of Texas Diabetic Wound Classification, as follows:

• Grade 0 – Pre- or Post-ulcerative with lesion completely epithelialized.
• Grade 1 – Superficial wound not involving tendon, capsule or bone.
• Grade 2 – Wound penetrating to tendon or capsule, not to bone.
• Grade 3 – Wound penetrating to bone or joint.

University of Texas Diabetic Wound Classification⁶: Grade 1, Grade 2, Grade 3

Report: I note no wounds or ulcers, no infection or discharge, no surrounding erythema or cellulitis, no swelling or fluctuance, and no visible bone on inspection.

Why Check: Wounds and ulcers are common in diabetes (re: peripheral neuropathy, peripheral vascular disease, and poor wound healing) and may go unnoticed by patients with neuropathy. Ulcers are concerning due to increased risk of infection, which can also present with skin infection (e.g. cellulitis) or progress to osteomyelitis (infection of underlying bone) if missed or untreated for a prolonged duration. Severe diabetes foot infections with osteomyelitis may require an amputation and can cause bacteremia/sepsis.

The likelihood of osteomyelitis in patients with foot ulcers is proportionally impacted by increasing ulcer area size (e.g. Ulcer area >3cm² → LR+ 3.5, LR- 0.3; Ulcer area >5cm² → LR+ 11.0, LR- 0.5), and is also slightly increased by positive bone probe test (LR+ 5.3, LR- 0.2) or ulcer depth >3mm/visible bone exposed (LR+ 3.9, LR- 0.3). Erythema, swelling and purulence as a finding on its own is not statistically significant.

The likelihood of a non-healing wound at 20 weeks increases with 3 findings: Ulcer Grade 3 or higher (full thickness and subcutaneous tissue involvement with exposed tendon, ligament or joint), Ulcer size >2cm2, and duration >2 months. Having all 3 of these findings mildly increases the likelihood of a non-healing wound at 20 weeks (LR+ 3.84), while having none of these findings moderately decreases the likelihood (LR+ 0.48).

Say: I will now inspect the shape of the foot, and shoes for their wearing pattern.

Do: Look for Charcot Foot (occurs due to bumping into items without feeling re: peripheral neuropathy). Look in shoes for areas where shoes are worn out (in Charcot Foot, occurs more on medial side of shoe).

Report: There are no abnormal wearing patterns in patients’ shoes, and the foot has a normal arch shape with no Charcot Foot.

Why Check: Patients with peripheral neuropathy may not notice trauma to their feet, and the trauma can accumulate over time. This may also speak to the patient’s foot-care management (recommend patients check their legs and feet every day for ulcers and sensation)

Say: I would like to examine your gait with walking. Could you stand up and walk up and down the room, turning around to continue walking when you get to the end of the room?

Do: Assess patient’s gait for symmetry/balance. Assess how they turn – quick, slow, staggered? Observing for patients’ gait. Assess whether they’re adopting an antalgic gait re avoiding movements causing pain.

Say: Can you please walk on the toes with both feet? And now the heels with both feet?

Do: Assess the patient’s gait for symmetry/balance.

Say: Are you in any pain when you walk (re: foot damage, ulcers, Charcot’s Foot)? Does it feel like you are walking on foam/cotton wool, or are unable to feel the roughness of the ground (re: peripheral neuropathy)?

Report: I note no gait abnormalities, with good symmetry, balance and quick turning.

Why Check: Assessing gait can provide a functional assessment of impact of chronic diabetes foot damage. It is important to note that patients with peripheral neuropathy may not present with an antalgic gait even with ulceration or foot damage. Gait can help assess peripheral neuropathy, looking at balance and heel walking. The likelihood of peripheral neuropathy is mildly decreased by no inability to walk on heels (LR- 0.76).

Say: I will now test sensation in the feet, beginning with a monofilament test. I will ask you to close both eyes, and lightly press on each foot several times with this monofilament (show monofilament to patient). Say “yes” when you feel a light touch.

Setup: Need a 10-mmHg monofilament (a standardized tool to make sure you’re applying same pressure).

Do: Press monofilament near sternal notch of chest of patient re sure to feel, then proceed to do so at locations indicated on diagram.

Report: I note a negative monofilament test, where each of the 10 locations tested elicited a patient response.

Why Check: Assessing for presence of sensory peripheral neuropathy via testing of the Posterior Columns (explored in Ch 31 – Screening Neuro Exam – MF4). The likelihood of peripheral neuropathy is greatly increased by inability to feel the monofilament in ≥5 of 8 trials (LR+ 11), while it is decreased by inability to feel the monofilament in only 0-1 of 8 trials (LR+ 0.54). Further, inability to feel the monofilament mildly increases the likelihood of subsequent foot ulceration (LR+ 2.4, LR- 0.5).

Say: I will now test sensation in the feet, using a tuning fork. I will ask you to close both eyes, and then the tuning fork will feel like a vibration when the tuning fork touches the foot (show tuning fork to patient). Please tell me when you begin to feel the vibration sensation, and when you can no longer feel the vibration sensation.

Setup: Use 128 Hz tuning fork. Test on your own sternum first. Strike the tuning fork hard so will vibrate for 40 seconds, then place it on the patient’s sternum to provide them a reference.

Do: Test dorsum of first toe on feet, as well as Medial Malleolus, Metatarsal Joint and Head of 1st Metatarsal Bone. Repeat the strike between each location. Ask the patient to report when they feel the vibrating tuning fork first placed on their feet, and then when the vibration dampens.

Grading: 1st point if patient can perceive vibration sensation (on); 2nd point if patient can perceive vibration dampening (off).

Report: I note a normal vibration test, where each time the patient sensed both the on sensation when the tuning fork was applied and the off sensation when the tuning fork was removed from the foot.

Why Check: Assessing for presence of sensory peripheral neuropathy via testing of the Posterior Columns (explored in Ch 31 – Screening Neuro Exam – MF4). The likelihood of peripheral neuropathy is greatly increased by inability to feel on-off sensation in ≥5 of 8 trials (LR+ 35), slightly increased by inability to feel on-off sensation in 2-4 of 8 trials (LR+ 3.9) and decreased by inability to feel on-off sensation in only 0-1 of 8 trials (LR+ 0.51). Further, the likelihood of peripheral neuropathy is greatly increased by timed toe vibration testing >20s sensation (LR+ 16), while it is decreased by <11s sensation (LR+ 0.33).

Say: I will now test sensation in the feet by testing your sense of direction with toe pointing. I will ask you to close both eyes, then point the toe with my hand up or down, and ask you which direction the toe is pointing.

Setup: Stabilize the joint you’re testing and grab a toe from its sides. While the patient’s eyes are open, demonstrate “up” by extending the toe, and “down” by flexing the toe. Then have the patient close their eyes and tell you if they can feel their toe moving up or down.

Do: Move toe up or down, randomly, each time asking patient whether it is up or down.

Report: I note a normal proprioception test, where each time the patient sensed the direction of toe movement.

Why Check: Assessing extent of peripheral neuropathy elicited via testing of the Posterior Columns (explored in Ch 31 – Screening Neuro Exam – MF4).

Say: I will now test the Achilles Tendon reflex using a reflex hammer. Please keep the leg relaxed.

Do: Loosen the patient’s ankle joint by rolling it around. Tap Achilles Tendon with reflex hammer. If patient’s reflex is difficult to elicit, can try the Jendrassik Maneuver (patient’s teeth clenched, fingers interlocked, and pull on the count of 3) for distraction. Clonus = seizure of the reflex (normal to see 2 beats of flapping of the foot).

Grading: 0 = Absent; 1+ = Hypoactive (or requiring Jendrassik Maneuver); 2+ = Normal; 3+ = Hyperactive, no Clonus; 4+ = Hyperactive, with Clonus

Report: I note a normal Grade 2+ Ankle Jerk Reflex bilaterally.

Why Check: Can help assess the extent of peripheral neuropathy. The ankle deep-tendon reflex (DTR) is innervated by S1-S2 (Tibial Nerve) (explored in Ch 31 – Screening Neuro Exam – MF4). Absence of deep tendon reflexes mildly increases the likelihood of suspected peripheral neuropathy (LR+ 3.6, LR- 0.36).

1. Have you ever felt tingling, numbness or heaviness in your hands or legs?
2. Have you ever felt burning, stabbing pain, pains, or cramps in your legs or arms?
3. Have you ever felt as if you were walking on foam or cotton wool or have you been unable to feel the unevenness (roughness) of the ground while walking?
4. Are you unable to feel the pain of a burning or a cut?
5. Have you ever felt weakness in your legs while climbing or descending stairs?
6. Have you ever felt faint or dizzy on rising from bed?
7. Do you have difficulty in starting to urinate or loss of control of bladder function?
8. Do you have diarrhea, particularly in the night?
9. Have you ever sweat abundantly from your face only?
10. Do you have difficulty in maintaining an erection? (Men only)

Scoring: Score each item from 0 (no) to 1 (sometimes) to 2 (often). Positive screen if sum of all scores is >4, needing a score of 2 on either question 3, 4, 9 or 10.

1. Appearance of Feet → Abnormal, Score = +1
2. Ulceration → Present, Score = +1
3. Ankle Reflexes → Present with Reinforcement = +0.5; Absent = +1
4. Vibration Proprioception → Reduced = +0.5; Absent = +1

Scoring: Score each item and add up the scores; 2 or greater is abnormal

Total Score: Sum of the four components; 6 or greater is abnormal