Case #4 Diabetes Mellitus

D. Describe the imaging and other diagnostic test done on the patient.

Breast Examination
The goal of the breast examination is to determine if the breasts are normal or abnormal. If
abnormal, any or all of the following may be indicated: surgical consultation, reexamination at a
different time of the menstrual cycle, mammograms, and possibly ultrasound.
Basic requirements for a proper breast examination include the following:
 Patient undressed down to the waist.
 Examining table with access from both sides.
 A mobile bright light with an assistant to focus the light from one area to another as the
examination is being conducted.
Adequate breast examination is performed by careful inspection and palpation. This requires a
routine planned procedure with several changes in the patient's position and meticulous
palpation of the entire extent of the breasts, which commonly cover most of the anterior chest
wall.

Blood Chemistry Test

Blood tests that measure amounts of certain chemicals in a sample of blood. They show how
well certain organs are working and can help find abnormalities.
There are many types of blood chemistry tests. They measure chemicals including enzymes,
electrolytes, fats (also called lipids), hormones, sugars, proteins, vitamins and minerals. Often
several chemicals are grouped together and measured at the same time. Different tests may be
used to measure different types of chemicals. The following are some common blood chemistry
tests:
 Electrolyte panel measures sodium, potassium, chloride, magnesium, phosphate and
bicarbonate.
 Kidney function tests (also called a renal panel) measure blood urea nitrogen (BUN) and
creatinine.
 Liver function tests measure alanine aminotransferase (ALT), alkaline phosphatase
(ALP), aspartate transaminase (AST), bilirubin, albumin and total protein.
 Basic metabolic panel (BMP) includes an electrolyte panel and kidney function tests and
also measures glucose and calcium.
 Comprehensive metabolic panel (CMP) includes an electrolyte panel, kidney function
tests and liver function tests and also measures glucose and calcium.
Urinalysis
A urinalysis is a test of your urine. A urinalysis is used to detect and manage a wide range of
disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves
checking the appearance, concentration and content of urine. Abnormal urinalysis results may
point to a disease or illness.

Neurological exam
A neurological exam, also called a neuro exam, is an evaluation of a person's nervous system
that can be done in the healthcare provider's office. It may be done with instruments, such as
 lights and reflex hammers. It usually does not cause any pain to the patient. The nervous system
consists of the brain, the spinal cord, and the nerves from these areas. There are many aspects
of this exam, including an assessment of motor and sensory skills, balance and coordination,
mental status (the patient's level of awareness and interaction with the environment), reflexes,
and functioning of the nerves. The extent of the exam depends on many factors, including the
initial problem that the patient is experiencing, the age of the patient, and the condition of the
patient.
There are 7 categories of neurological exam: Mental status, Cranial nerves, motor system,
reflexes, sensory system, coordination, station and gait.

Genital Examination
For women, the genital exam involves a pelvic exam. The pelvic exam allows a doctor or health
care provider to check the internal and external reproductive organs for signs of disease. In
females the reproductive organs include the vulva (the outside of the vagina), the vagina, the
cervix, the uterus, the fallopian tubes, and the ovaries. Various lymph nodes in the groin area
are also examined. The pelvic exam is often accompanied by a pap smear, which is when a
sample of cells is removed from the cervix for testing.

Rectal Examination
Rectal examination consists of visual inspection of the perianal skin, digital palpation of the
rectum, and assessment of neuromuscular function of the perineum.

Skin Assessment
Captures the patient's general physical condition, based on careful inspection and palpation of
the skin.
Techniques of examination: Inspect and palpate all skin lesions, focusing on key features that
help distinguish if lesions are benign or suspicious for malignancy.

Vital Signs Examination

Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure
and, where appropriate, blood oxygen saturation. These numbers provide critical information
about a patient's state of health.

HEENT Examination
HEENT examination is a portion of a physical examination that principally concerns the head,
eyes, ears, nose, and throat.

Neck and Lymph Nodes Examination

Techniques of Examination: Inspect the neck, noting its symmetry and any masses or scars. Look
for enlargement of the parotid or submandibular glands, and note any visible lymph nodes.
The Lymph Nodes. Palpate the lymph nodes. Using the pads of your index and middle fingers,
press gently, moving the skin over the underlying tissues in each area. The patient should be
relaxed, with the neck flexed slightly forward and, if needed, turned slightly toward the side
being examined. You can usually examine both sides at once, noting both the presence of lymph
 nodes as well as asymmetry. For the submental node, however, it is helpful to feel with one
hand while bracing the top of the head with the other.

Chest and Lungs Examination

The pulmonary examination consists of inspection, palpation, percussion, and auscultation. The
inspection process initiates and continues throughout the patient encounter. Palpation,
confirmed by percussion, assesses for tenderness and degree of chest expansion. Auscultation, a
more sensitive process, confirms earlier findings and may help to identify specific pathologic
processes not previously recognized.

Cardiovascular Examination
The major elements of the cardiac exam include observation, palpation and, most importantly,
auscultation (percussion is omitted). As with all other areas of the physical exam, establishing
adequate exposure and a quiet environment are critical. Initially, the patient should rest supine
with the upper body elevated 30 to 45 degrees.
Inspection: Careful inspection of the anterior chest may reveal the location of the apical impulse
or PMI, or less commonly, the ventricular movements of a left-sided S3 or S4. Shine a tangential
light across the chest wall over the cardiac apex to make these movements more visible.
Palpation: Begin with general palpation of the chest wall. In women, keeping the right chest
draped, gently lift the breast with your left hand or ask the woman to do this to assist you.
Percussion: Palpation has replaced percussion when estimating cardiac size. If you cannot
palpate the apical impulse, percussion may be your only option, but has limited correlation with
the cardiac borders. Starting well to the left on the chest, percuss from resonance toward
cardiac dullness in the 3rd, 4th, 5th, and, possibly, 6th interspaces.
Auscultation: Auscultation of heart sounds and murmurs is a pre-eminent skill that leads directly
to important clinical diagnoses.

Musculoskeletal and Extremities Examination

The musculoskeletal examination serves to evaluate the integrated functioning of bones, joints,
supporting ligaments, and muscular tissue. Information from the examination can be used to
localize possible sources of pain in various structures, including the skin, subcutaneous tissue,
tendons, joints, ligaments, and periosteum. The format of the musculoskeletal examination
follows the steps of inspection, palpation, range of motion, and special tests. The components
tested are the spine (cervical, thoracic, and lumbar) and the extremities with their respective
joints.

Electrocardiogram
Electrocardiogram records the electrical signals in your heart. It's a common and painless test
used to quickly detect heart problems and monitor your heart's health.

References:
 Benzon, et al. (2014). Musculoskeletal Examination. Practical Management of pain. Elsevier Inc.
 Bickley, L.S. (2013). Bate’s guide to physical examination and history taking (12 th Ed.). pp 180,
259, 384-389. Wolters Kluwer.
  Powell, R.W. (1990). Clinical Methods: The History, Physical, and Laboratory Examinations (3 rd
Ed). Boston
 https://www.hopkinsmedicine.org/health/conditions-and-diseases/neurological-exam
 https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-
procedures/blood-chemistry-tests/?region=on
 https://www.mentalhelp.net/sexuality/std/examination/

Patient Case Question 10

List a minimum of five risk factors that predispose this patient to type 2 diabetes mellitus.
are age 45 or older
have a family history of diabetes (Younger sister and maternal grandmother)
Belongs to Winnebago Indian tribe
have a history of gestational diabetes
have high blood pressure (HTN x 10 years)
Reference:
 Fletcher, et al. (2002). Risk factors for type 2 diabetes mellitus. The Journal of Cardiovascular
Nursing.
 https://www.niddk.nih.gov/health-information/diabetes/overview/risk-factors-type-2-diabetes

Patient Case Question 11

Clinical symptoms are subjective manifestations of a disease that can only be reported by the patient.
List a minimum of seven symptoms that support a diagnosis of type 2 diabetes in this patient.
Nocturia
 You’ll pee more because your kidneys are working to get rid of extra sugar in your
system.
Excessive thirst
 When sugar builds up in your blood, your kidneys work overtime to get rid of it. This
pulls fluids from your tissues and makes you dehydrated, so you feel thirsty.
Fatigue
 Body can’t use energy from food
Blurred vision
 High blood sugar can make you have trouble focusing.
Frequent infections
 High blood sugar can slow blood flow and make it harder for your body to heal.
Numbness in the feet
 Symptom of neuropathy or nerve damage, one of the most common long-term
complications of type 2 diabetes.
Itching (Xerosis)

Reference:
 Ramachandran, A. (2014). Know the signs and symptoms of diabetes. Indian Journal of Medical
Research.
Patient Case Question 12
What has probably caused this patient’s left ventricular hypertrophy?
The probable cause is high blood pressure. As stated in her past medical history, she had
hypertension for 10 years. High blood pressure is one of the most common causes of left
ventricular hypertrophy.

Reference:
 https://my.clevelandclinic.org/health/diseases/17168-left-ventricular-hypertrophy-enlarged-
heart