OSCE — assessment and management plan for a newly diagnosed type 2 diabetic with the diabetic foot

An 8-minute OSCE station assessing the candidate's structured assessment of a 60-year-old with type 2 diabetes and a new foot ulcer — foot examination (pulses, 10-g monofilament sensation), recognition of the diabetic foot emergency, and a management plan including the glycaemic/blood-pressure/lipid ladder with drug doses.

Brief (to candidate)

A 60-year-old man with a 10-year history of type 2 diabetes (currently on metformin and gliclazide) presents with a painful ulcer on the plantar surface of the right great toe for 5 days. He also reports two months of intermittent calf claudication. HbA1c 9.1 percent, BMI 30 kg/m², BP 150/88, eGFR 60 mL/min/1.73 m².^[1] You have 8 minutes to assess him (including the foot), recognise the urgency, and outline a management plan with named drugs and doses.

Candidate instructions

Take a focused, structured history and examine the diabetic foot in a structured way.^[3]
Identify and grade the foot problem (neuropathic vs ischaemic vs infected) and state the urgency.
Outline the glycaemic, blood-pressure and lipid management, including drug doses and escalation triggers.
State your disposition (urgent multidisciplinary foot-team referral, admission criteria) and safety-net advice.

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
History & general assessment	Duration, glycaemic control, claudication/rest pain, prior ulcer/amputation, smoking, footwear; BP, BMI, complication screening
Foot examination	Inspects for deformity, callus, ulcer, infection; palpates dorsalis pedis and posterior tibial pulses; tests sensation with 10-g monofilament and 128-Hz tuning fork; checks ankle reflexes
Problem classification	Identifies likely mixed neuropathic-ischaemic foot with infection; recognises this as a diabetic foot emergency needing urgent multidisciplinary referral
Investigations	Wound swab/bone sampling, blood glucose and HbA1c, FBC, CRP, renal function, X-ray/MRI for osteomyelitis, Doppler/ABPI, urgent vascular review
Glycaemic ladder	Confirms metformin dose/limits (eGFR 60 — continue but monitor); adds an SGLT2 inhibitor or GLP-1 receptor agonist; escalates to insulin (start basal 10 units/day or 0.1 to 0.2 units/kg/day, then add prandial boluses and titrate) given HbA1c 9.1 percent and infection^[1]
Infection & ischaemia	Broad-spectrum antibiotics for infection (e.g. amoxicillin-clavulanate; broaden for severe/deep); offloading (total contact cast); urgent revascularisation if ischaemic
BP / lipids / disposition	ACE inhibitor for BP/albuminuria to below 130/80; high-intensity statin; urgent foot-team/vascular referral; admit if deep infection, sepsis or critical ischaemia

Model key actions

Foot exam reproduced: reduced pulses and loss of monofilament sensation indicate a mixed neuropathic-ischaemic ulcer; warmth, surrounding cellulitis or pus = infection (a diabetic foot emergency).^[3]
Glycaemic control: confirm metformin dose and do not exceed limits in CKD (adjust the dose below eGFR 45, stop below 30 mL/min/1.73 m²);^[9] given HbA1c 9.1 percent with infection, escalate to insulin (start basal 10 units/day or 0.1 to 0.2 units/kg/day, then add prandial boluses and titrate to glucose).^[1]
Multidisciplinary care: urgent referral to the diabetic foot team; offloading, debridement, swab-guided antibiotics, and vascular assessment (Doppler/ABPI, revascularisation if ischaemic).^[3]
Risk-factor control: ACE inhibitor for BP below 130/80 and any albuminuria; high-intensity statin; smoking cessation; structured education.

Common errors

Treating the ulcer as trivial and not recognising the diabetic foot emergency (risk of amputation/sepsis).
Not palpating pulses or testing 10-g monofilament sensation — missing ischaemia or loss of protective sensation.
Continuing metformin without regard to the eGFR (CKD) dose limits, or failing to escalate to insulin in the face of HbA1c 9.1 percent and infection.
Giving glucose-only advice and ignoring blood-pressure and lipid control and multidisciplinary referral.
Not addressing offloading, debridement and vascular review — the measures that actually heal the foot.^[3]

References4Show

[1]Tegegne BA, et al. A critical review on diabetes mellitus type 1 and type 2 management approaches. Front Endocrinol, 2024.PMID 39493778
[3]American Diabetes Association Professional Practice Committee Summary of Revisions: Standards of Care in Diabetes-2024. Diabetes Care, 2024.PMID 38078579
[8]UKPDS Group Effect of intensive blood-glucose control with metformin ... (UKPDS 34). Lancet, 1998.PMID 9742977
[9]de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Care, 2022.PMID 36189689

OSCE — assessment and management plan for a newly diagnosed type 2 diabetic with the diabetic foot

Brief (to candidate)

Candidate instructions

Take a focused, structured history and examine the diabetic foot in a structured way.^[3]

Identify and grade the foot problem (neuropathic vs ischaemic vs infected) and state the urgency.

Outline the glycaemic, blood-pressure and lipid management, including drug doses and escalation triggers.

State your disposition (urgent multidisciplinary foot-team referral, admission criteria) and safety-net advice.

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
History & general assessment	Duration, glycaemic control, claudication/rest pain, prior ulcer/amputation, smoking, footwear; BP, BMI, complication screening
Foot examination	Inspects for deformity, callus, ulcer, infection; palpates dorsalis pedis and posterior tibial pulses; tests sensation with 10-g monofilament and 128-Hz tuning fork; checks ankle reflexes
Problem classification	Identifies likely mixed neuropathic-ischaemic foot with infection; recognises this as a diabetic foot emergency needing urgent multidisciplinary referral
Investigations	Wound swab/bone sampling, blood glucose and HbA1c, FBC, CRP, renal function, X-ray/MRI for osteomyelitis, Doppler/ABPI, urgent vascular review
Glycaemic ladder	Confirms metformin dose/limits (eGFR 60 — continue but monitor); adds an SGLT2 inhibitor or GLP-1 receptor agonist; escalates to insulin (start basal 10 units/day or 0.1 to 0.2 units/kg/day, then add prandial boluses and titrate) given HbA1c 9.1 percent and infection^[1]
Infection & ischaemia	Broad-spectrum antibiotics for infection (e.g. amoxicillin-clavulanate; broaden for severe/deep); offloading (total contact cast); urgent revascularisation if ischaemic
BP / lipids / disposition	ACE inhibitor for BP/albuminuria to below 130/80; high-intensity statin; urgent foot-team/vascular referral; admit if deep infection, sepsis or critical ischaemia

Model key actions

Foot exam reproduced: reduced pulses and loss of monofilament sensation indicate a mixed neuropathic-ischaemic ulcer; warmth, surrounding cellulitis or pus = infection (a diabetic foot emergency).^[3]

Glycaemic control: confirm metformin dose and do not exceed limits in CKD (adjust the dose below eGFR 45, stop below 30 mL/min/1.73 m²);^[9] given HbA1c 9.1 percent with infection, escalate to insulin (start basal 10 units/day or 0.1 to 0.2 units/kg/day, then add prandial boluses and titrate to glucose).^[1]

Multidisciplinary care: urgent referral to the diabetic foot team; offloading, debridement, swab-guided antibiotics, and vascular assessment (Doppler/ABPI, revascularisation if ischaemic).^[3]

Risk-factor control: ACE inhibitor for BP below 130/80 and any albuminuria; high-intensity statin; smoking cessation; structured education.

Common errors

Treating the ulcer as trivial and not recognising the diabetic foot emergency (risk of amputation/sepsis).

Not palpating pulses or testing 10-g monofilament sensation — missing ischaemia or loss of protective sensation.

Continuing metformin without regard to the eGFR (CKD) dose limits, or failing to escalate to insulin in the face of HbA1c 9.1 percent and infection.

Giving glucose-only advice and ignoring blood-pressure and lipid control and multidisciplinary referral.

Not addressing offloading, debridement and vascular review — the measures that actually heal the foot.^[3]

References4Show

[1]Tegegne BA, et al. A critical review on diabetes mellitus type 1 and type 2 management approaches. Front Endocrinol, 2024.PMID 39493778
[3]American Diabetes Association Professional Practice Committee Summary of Revisions: Standards of Care in Diabetes-2024. Diabetes Care, 2024.PMID 38078579
[8]UKPDS Group Effect of intensive blood-glucose control with metformin ... (UKPDS 34). Lancet, 1998.PMID 9742977
[9]de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Care, 2022.PMID 36189689