Assessment of a patient with newly diagnosed diabetes

Look for evidence of:

• Weight loss – seen in Type 1 DM
• Obesity – seen in Type 2 DM
• Dehydration – dry mucous membranes, reduced skin turgor
• Mucosal candidiasis
• Clinical features of:
  • Cushing’s syndrome
    • Centrally distributed fat
    • Skin changes: Thinning, bruising, striae
    • Buffalo hump
    • Moon facies
    • Raised blood pressure
    • Proximal myopathy – difficulty getting up from a seat
  • Acromegaly
    • Coarse features
    • Prognathism with spaced-out lower teeth
    • Enlarged hands and feet
    • Elevated blood pressure
• Kussmaul breathing – ketoacidosis
• syndromic features
• Sweet acetone smell on breath – ketoacidosis
• Skin
  • Cellulitis
  • Skin ulcers
  • Abscesses
  • Fungal infections
  • Acanthosis nigricans
  Examination of the feet will be handled in a different section.
• Signs of dyslipidemia
  • Xanthelasmata
  • Xanthomatas
• Measure blood pressure and pulse
• Hands
  • Limited joint mobility (‘cheiroarthropathy’) causes painless stiffness. The inability to extend (to 180°) the metacarpophalangeal or interphalangeal joints of at least one finger bilaterally can be demonstrated in the ‘prayer sign’.
  • Muscle-wasting/sensory changes may be present in peripheral sensorimotor neuropathy, although this is more common in the lower limbs
• Facial nerve palsy
  • Microcirculatory insufficiency due to peripheral vascular disease is seen in the causes of facial palsy, characterized by sudden hemifacial weakness.
• Visual acuity and fundoscopy – screen for diabetic retinopathy
• Hepatomegaly – fatty infiltration of the liver
• Legs
  • Muscle-wasting
  • Sensory abnormality
  • Hair loss
  • Tendon reflexes
• Neck
  • Carotid pulse
  • Bruits
  • Thyroid enlargement

Routine Review of a known DM patient

• Weight measurement
  • Loss of weight in type 1 DM indicates insulin deficiency
  • An increase in weight in type 2 DM indicates increased insulin resistance
• Mucosal candidiasis
• Examine hands as mentioned above
• Measure BP and pulse
• Test visual acuity and fundoscopy
• Routine investigations
• Examine injection sites for (Sites to look at: Anterior abdominal wall, upper thighs and buttocks, upper, outer arms)
  • Lipohypertrophy – causes unpredictable insulin release
  • Lipoatrophy
  • Infection
  Examination of a Diabetic Foot You’re worried about:
  • Neuropathy
  • Ischemia
  • Infection
  • A mix of all of these
  • Inspection
    • Hair loss and nail dystrophy – fungal infections, etc
    • Discoloration – gangrene
    • Pallor – ischemia
    • Excessive calluses
    • Clawing of toes – neuropathy
    • Skin breaks, ulcers – ischemic ulcers are found on the tips of toes
    • Loss of plantar arch – ask the patient to stand
    • Joint deformity – Charcot neuropathy
  • Palpation Vascular
    • Palpate peripheral pulses – dorsalis pedis and posterior tibial arteries
    • Skin temperature
      • Warm – neuropathy
      • Cold – ischemia
    • Capillary refill
    Peripheral Neuropathy
    • Use a 10g monofilament to apply a standard, reproducible stimulus at specific points
      • Used as a form of risk assessment
      • If it perceives less than 8 out of ten then there is an increased risk for ulceration
      • Note sensory deficiency in a stocking pattern
    • Test for vibration and proprioception
    • Test for ankle and plantar reflexes
  • Charcot arthropathy
    • Progressive condition characterised by joint dislocation, pathological fractures, and deformity
    • Occurs in DM most commonly, but can be seen in:
      • Chronic alcoholism
      • Leprosy
      • Syphllis
      • Spinal cord injury
      • Renal dialysis
    • Thought to occur due to unperceived trauma or injury to an insensate foot resulting from sensory neuropathy renders the patient unaware of the osseous destruction that occurs with ambulation.
    • This microtrauma leads to progressive destruction and damage to bone and joints.