Assessment of Diabetic Patient.

Assessment of Diabetic Patient

This is going to be a wide topic - but let me try.

the examination of Diabetic foot ulcer will be discussed separately.

Things to keep in mind while assessing Diabetic Patients (when you FIRST see them) 

we like to look at diabetic patients, largely for 4 things;

presence of acute modbid conditions associated with Diabetes

presence of possible causes of diabetes

co-morbidities present

complications of diabetes

• acute presentation of diabetic complications
• hypoglycemia 
• confused, sweating, anxious, hungry, trembling, dizzy patient 
• Diabetic Ketoacidosis 
• deep, dapid breathing, flushed face, abdominal pain, fruity odour, nausea and vomiting. 
• presence of possible etiologies of current diabetes
• Metabolic disease and lifestyle habits
• pancreactomy 
• PCOS (ladies)
• Cushings, Thyrotoxicosis, 
• Drug-induced 
• phenytoin, Diuretics etc
• presence of possible co-morbidities
• hypertension
• dyslipidaemia
• presence of possible end-organ damage due to direct effect of diabetes
• diabetic Eye disease 
• background retinopathy
• proliferative retinopathy
• maculopathy
• cataracts
• rubeosis iridis*1 -> glaucoma
• diabetic Nephropathy
• diabetic Neuropathies
• peripheral neuropathy
• autonomic neuropathy
• radiculoplexus neuropathy (diabetic amyotrophy) *2
• mononeuropathy - focal neuropathy *3
• cranial neuropathy (mostly 3rd nerve) 
• Cardiovascular Disease & peripheral vascular disease 
• CAD
• PVD (claudication)
• cerebrovascular disease 
• TIA 
• altered immunologic response and hence, infection
• skin infections
• cellulitis
• erysipelas
• lymphangitis
• inguinal skin infections (mostly fungal)
• lung infections
• some infections are found almost exclusively in diabetics such as;
• malignant otitis externa
• rhinocerebral mucomycosis
• emphysematous pyelonephritis 
• UTI

keeping the above in mind, we would like to assess a diabetic patient.

Assessment of Diabetic Patient

history taking

• hyperglycemic symptoms
• polyurea, 
• polydipsia
• weight loss
• recurrent infection
• hypoglycemic symptoms
• palpitations
• tremors
• sweating
• dizziness
• syncope
• complications of diabetes
• chest pain
• oedema
• shortness of breath
• blurring of vision
• parasthesia
• numbness / weakness
• risk factor assessment
• smoking
• sedentary lifestyle
• alcohol

General Assessment

firstly during history taking, some questions may be asked to specifically rule out hypoglycemia and

• Mentation - ruling out Diabetic Ketoacidosis / hypoglycemia 
• Vital Signs
• Blood Pressure
• Pulse
• Respiratory rate
• hydration state
• Lifestyle assessment (if non-acute)
• BMI
• waist circumference 
• Waist-hip ratio
• orthostatic Blood Pressure

Locoregional Assessment (head to toe)

• Hands
• pallor 
• capillary refill
• fungal nail infections 
• tinnel's sign, phalen's sign - for carpal tunnel syndrome
• dupuytren's contracture - associated with Diabetes. 
• pallor (anemia of chronic diabetic renal disease)
• arms
• uremic frost - renal 
• scratch marks
• Head
• eyes
• anemia
• cataracts
• rubeosis iridis and glaucoma
• fundus examination
• visual acuity
• xanthelasma
• pupillary light reflex
• nose
• sinus tenderness
• ears 
• any discharge, lymphadenitis (malignant otitis externa)
• mouth
• oral health
• gum hypertrophy (gingivitis)
• periodontitis  
• candida
• Neck
• carotid pulse
• carotid bruit
• thyroid
• acanthosis nigricans 
• Chest
• cardiovascular examination
• 
  
• Abdomen
• surgical scars 
• pancreactomy
• kidney transplant
• complications of insulin injection
• lipodystrophies 
• renal artery bruit
• Pelvis
• signs of fungal infections
• UTI
• Legs
• skin changes
• lipodermatosclerosis 
• necrobiosis lipoidica diabeticorum*4
• Foot
• diabetic foot is a whole new chapter. 

*1

neovascularization around the iris - the newly formed vessels may evantually fibrose, to close the angle, causing increase in intraocular pressure to cause "neovascular glaucoma". 

*2

Radiculoplexus neuropathy (diabetic amyotrophy) 

radiculoplexus neuropathy affects nerves in the thighs, hips, buttocks or legs. Also called diabetic amyotrophy, femoral neuropathy, or proximal neuropathy, this condition is more common in people with type 2 diabetes and older adults. Symptoms are usually on one side of the body, though in some cases symptoms may spread to the other side too. Most people improve at least partially over time, though symptoms may worsen before they get better. This condition is often marked by:

• Sudden, severe pain in your hip and thigh or buttock
• Eventual weak and atrophied thigh muscles
• Difficulty rising from a sitting position
• Abdominal swelling, if the abdomen is affected
• Weight loss

*3

Mononeuropathy involves damage to a specific nerve. The nerve may be in the face, torso or leg. Mononeuropathy, which may also be called focal neuropathy, often comes on suddenly. It's most common in older adults. Although mononeuropathy can cause severe pain, it usually doesn't cause any long-term problems. Symptoms usually diminish and disappear on their own over a few weeks or months. Signs and symptoms depend on which nerve is involved and may include:

• Difficulty focusing your eyes, double vision or aching behind one eye
• Paralysis on one side of your face (Bell's palsy)
• Pain in your shin or foot
• Pain in the front of your thigh
• Chest or abdominal pain

Sometimes mononeuropathy occurs when a nerve is compressed. Carpal tunnel syndrome is a common type of compression neuropathy in people with diabetes.

Signs and symptoms of carpal tunnel syndrome include:

• Numbness or tingling in your fingers or hand, especially in your thumb, index finger, middle finger and ring finger
• A sense of weakness in your hand and a tendency to drop things

*4appears as a hardened, raised area of the skin. The center of the affected area usually has a yellowish tint while the area surrounding it is a dark pink. It is possible for the affected area to spread or turn into an open sore. When this happens the patient is at greater risk of developing ulcers. If an injury to the skin occurs on the affected area, it may not heal properly or it will leave a dark scar.

Chronic assessment of diabetic patient

• BMI monitering 
• retinal examination for diabetic retinopathy
• orthostatic blood pressure for autonomic neuropathy
• foot examination 
• periphiral pulses
• insulin injection site 
• periodontal health 

things to note 

differences between type 1 DM and type 2 DM

type 1 DM patients tend to be....

• younger (>30) in onset
• lean 
• requiring insulin as initial therapy
• likely to develop ketoacidosis
• increased risk of other autoimmune illness such as autoimmune thyroid disease, adrenal insufficiency, pernicious anemia, celiac disease and vitiligo 

type 2 DM patients tend to be...

• older in onset (>30)
• usually obese (approx. 80%) - elderly patients more likely to be lean
• may not require insulin initially
• may have associated conditions such as insulin resistence, hypertension, CVS diseases, dyslipidemia, PCOS. 
• insulin resistance is often correlated with abdominal obesity and Hyper triglyceridemia. 

some more extra info....

• age of onset becoming younger in DM2 due to change in dietary habits worldwide
• some DM2 patients also present with DKA - called ketosis prone DM2 

Brief discussion of Essential elements in comprehensive diabetic care in DM2. 

there are, largely divided three essential goals in treatment of DM2 -

1. glycemic control
2. treatment of associated conditions
3. screening and managing complications

whereas glycemic control is managed by both consideration for medication and dietary and exercise habits; associated conditions are managed according to the illnesses each patient may have, and high index of suspicion for complications before it has fully manifested. 

therefore we can say that every diabetic patient - ideally - should receive a multi-disciplinary care of doctors, dietitians, pharmacists and diabetic educators.