THE DIABETIC EXAM

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COMPREHENSIVE HISTORY
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Severity, duration (age of Dx), and symptoms of diabetes SHx-1: situational factors, lifestyle, cultural, psychosocial, educational, and economic factors that might affect DM mgmt. SHx-2: smoking, drinking, exercise, drugs, diet. Sexual, contraceptive use, and reproductive Hx.
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Eating patterns, nutritional status, weight history; physical growth and development (in children and adolescents)

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FHx, including diabetes, endocrine disorders, atherosclerosis, HTN, and dyslipidemia. Results of previous lab tests and exams related to DM (including A1C) Current Tx of diabetes; glucose monitoring results; current exercise and medications Modifying factors, including frequency, severity, and cause of acute complications (e.g. ketoacidosis and hypoglycemia) RFs for atherosclerosis Symptomological Hx
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Autonomic Neuropathy: urinary retention, gastroparesis, increased hunger, shaking/ trembling Peripheral Neuropathy: tingling, numbness, decreased sensation in hands/feet, foot ulceration. Retinopathy: inquire about ophtho appts, cataracts, vision trouble (e.g. blurring) Nephropathy: polyuria, polydipsia. Other: wound healing, macrovascular complications (e.g. angina), claudication, prior and current infxns of skin/teeth/gums/feet/GU system, altered mental status, weight loss, lethargy.

COMPREHENSIVE PHYSICAL EXAM

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Constitutional signs, including general appearance Vitals

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BP (orthostatic) Pulse (include peripherals), resp, temp, height & weight (compare to norms for children and adolescents) Blood sugar

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Eye: fundoscopy ENT: include lips, teeth and gums, oropharynx Neck: thyroid exam Resp: auscultation of lung fields CV: auscultation of heart, carotid arteries, and pedal pulses Extremities: inspect digits and nails; foot exam for callous formation or breakdown Abdomen: hepatomegaly Skin: acanthosis nigricans Neuropathis: deep tendon reflexes, foot sensation to light touch/ vibration Psychiatric: mood and affect, insight and judgment

FORMALITIES
!! Wash

hands !! Introduce self and exam !! Obtain consent !! Vitals (include postural, glucose)

INSPECTION
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General condition: well or unwell Body habitus: obesity (esp centripetal), BMI. Eyes: fundoscopy (retinopathy), pupillary reflexes (PERRLAC), extraocular movements, double vision, rubeosis iridis, xanthelasma Nose: mucormycosis. Mouth: thrush, angular chelitis, Kussmaul breathing, fruity breath Ears: malignant otitis externa Volume status: JVP, mucous membranes, skin turgor (diabetes polyuria diuresis) Skin: acanthosis nigricans (skin folds), scleroderma diabeticorum (DM2 -neck & back), vitiligo (DM1 -mouth, nostrils, eyes), eruptive xanthomatosis, bullosis diabeticorum (extremities), disseminated granuloma annulare (fingers, ears; chest, abdomen), rashes/ bumps (esp injection sites), bacterial skin infxns, ringworm. Trunk: sister mary joseph node, visually apparent hepatomegaly. Legs: see skin, signs of arterial or venous insufficiency, necrobiosis lipidoica diabeticorum, diabetic dermopathy (shins), ulcerations, hair loss/thinning/shiny skin. Xanthoma (achiles tendon), quadriceps wasting, superficial infxn. Feet: discolored toenails, athletes foot, onchomycosis, ulcerations (toe, heel),Charcots joints, calluses, fissures. Hands: onchomycosis (candidal infxn), digital sclerosis. Genitals: jock itch. Other: thyroid,

PALPATION
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Hands and feet: pulses, temperature, cap refill. Legs: pulses, edema. Motor: reflexes (patella, achilles) Sensory
Light touch: brush from foot to knee, bilateral, symmetry. !! Sharp: apply ~10mmHg pressure on bottom of feet, heel, and toe, using monofilament tool. !! Tuning fork: strike fork to elicit vibration, touch to toes and feet.
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!! Neurological

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Position: pt closes eyes while examiner moves toes up or down, pt must identify direction.

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thyroid, hepatomegaly

PERCUSSION
!! Hepatomegaly

AUSCULTATION
!! Precordial

auscultation !! Bruits (esp. carotid, femoral) !! Lung fields

DIABETIC LOWER LIMB EXAMINATION

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MSK
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Biomechanical abnormalities
Orthopedic abnormalities: hammer toes, bunions, Tailors bunions, flat or high-arched feet, Charcot deformities, iatrogenic deformities (e.g. amputations). !! Limited joint mobility !! Tendo-achilles contractures/equinus
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Gait evaluation: rearfoot evaluation, forefoot to rearfoot relationship, femoral rang of motion, knee position, tibial angle (torsion), leg length discrepancies, angle of gait. Muscle group strength testing: passive and active (nonweightbearing and weightbearing), foot drop, intrinsic muscle atrophy. Plantar pressure assessment: computerized devices, harris ink mat.

DIABETIC LOWER LIMB EXAMINATION

!! Vascular !! !! !! !! !! !! !!

Palpation of pulses (dorsalis pedis, posterior tibial, popliteal, femoral) Cap refill (!3s), venous filling (!20s) Color changes: cyanosis, dependent rubor, erythema. Edema Temperature gradient Dermal thermometry Integumental changes consistent with ischemia: skin atrophy, nail atrophy, abnormal wrinkling, diminished pedal hair.

DIABETIC LOWER LIMB EXAMINATION

!! Neurologic !!

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Vibration perception: 128 Hz tuning fork; measurement of vibration percetion threshold (Biothesiometer) Light pressure: Semmes-Weinstein (5.07 gague) 10gram monofilament Light touch: cotton wool Two-point discrimination Pain: pinprick Temperature perception: hot and cold Deep tendon reflexes: ankle, knee Babinski test Rhombergs test

DIABETIC LOWER LIMB EXAMINATION

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Dermatologic
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Skin appearance:
Color, texture, turgor, quality. !! Dry skin.
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Calluses: discoloration, subcallous hemorrhage. Fissures (esp posterior heels) Nail appearance: onchomycosis, dystrophic, atrophic, hypertrophic, paronychia. Presence of hair Ulceration, gangrene, infxn (note: location, size, depth, infxn status, etc.) Interdigital lesions Tinea pedis Markers of diabetes: shin spots (diabetic dermopathy), necrobiosis lipoidica diabeticorum, bullosum diabeticorum.

DIABETIC LOWER LIMB EXAMINATION

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Wound Description
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Location Dimensions (inc depth), quality of wound bed Describe edges (inc. undermining/tracking) Edema Exudate, type, amount, odor, color Presence of necrosis Surrounding erythema/cellulitis Mechanism of injury Penetration to deep structures Signs of infxn Sinus tracking Induration Classify acc to recognized wound clasification system: U of Texas wound classification system, or Wagner ulcer classification tool

DIABETIC LOWER LIMB EXAMINATION

!! Assess !! !!

for Ischemia

Non-invasice vascular testing (toe brachial pressure indes, pulse palpation, cap refill) Vascular lab studies

!! Examine !! !! !!

Footwear

Type of shoes, fit of shoes, patterns of wear on the lining and sole of the shoes. Presence of foreign bodies in the shoes Insoles, orthoses.