Exam Summary


1. Introduction

  • Introduce yourself and the exams
  • Wash your hands

2. Observations

3. General Inspection

Assess for:
  • Alertness
  • Body habitus - obesity
  • Signs of dehydration
    • Dry skin
    • Fatigue
    • Few or no tears when crying
  • Signs of Cushing's Syndrome, Acromegaly or Haemocromatosis (all secondary causes of diabetes)
  • Respiratory Rate - Abnormally fast and irregular breathing may be Kassmaul's breathing due to diabetic ketoacidosis
  • Breath - Assess for ketones
Cushing Syndrome.png
Cushing's Disease

4. Lower Limb and Feet

a. Inspection

Look for:
  • Hairlessness - may be due to reduced blood supply
  • Pallor - may be due to Peripheral vascular Disease
  • Muscle Atrophy - may be due to ischaemia (see Peripheral Vascular Disease) or neuropathy (eg Quadriceps muscles)
  • Ulcers
  • Charcot's joint - (also neuropathic arthropathy) deformed joint due to loss of proprioception
  • Skin infections including boils, fungus and cellulitis.
  • Thigh injection sites for fat atrophy or fat hypertrophy (this is rarer with modern insulins)
  • Amputations
  • Saphenous Vein graft
Neuropathic Arthropathy.jpg
Neuropathic Arthropathy (Charcot's Joint)
1024px-My_leg_with_cellulitis_and_oedema.jpg
Cellulitis


Fat Hypertrophy.jpg
Fat hypertrophy
Lipodystrophy.jpg
Lipodystrophy (Fat atrophy)

b. Palpation

  • Temperature - cold extremities suggests poor blood flow
  • Capillary refill - if prolonged beyond 3 seconds, it suggests poor arterial supply.
  • Pulses
    • Femoral
    • Popliteal
    • Posterior Tibial
    • Dorsalis Pedis
  • Consider doing Buergher's Test or Ankle Brachial Index if relevant
    • Elevate legs to 45º for 1 minute
    • Hang legs over bed at 90º
    • If the legs remain pale for >10 seconds then poor arterial supply is likely
Pulses.png
Pulses
toe refill.jpg
Capillary Refill

c. Auscultation

d. Neurological Examination

  • Monofilament
    • Big toe, middle toe, little toe
    • Metatarsals for big toe, middle toe, little toe
    • Medial and Lateral sole of foot halfway along foot
    • Heel
  • Light Touch - cotton wool
    • As above
  • Vibration
  • Proprioception
  • Reflexes
    • Knee Jerk (L2,L3,L4)
    • Ankle Jerk (S1, S2)
    • Plantar reflex – look for Babinski sign (L5,S1,S2) by running the nail of your thumb up the sole of their foot. Look only for the direction the big toe moves.
  • Proximal muscle strength - Particularly knee extension (quadriceps atrophy due to femoral mononeuropathy)
Dermatomes lower limbs.jpg
Dermatomes of the Lower Limb

5. Arms

a. Inspection

AV Fistula.jpg
Arterio-Venous Fistula

b. Palpation

  • Radial pulse

c. Blood Pressure

  • Both lying and standing - diabetes can cause autonomic neuropathy and postural hypotension

6. Neck

  • Palpate the carotids - vascular disease
  • Auscultate the carotids for bruits - vascular disease

7. Face

a. Visual Acuity

  • Assess the patient's Visual Acuity using a Snellen Chart
  • Assess the patient's Visual Field using a red pin.

b. Fundoscopy

  • Request Fundoscopy
  • Assess for:
    • New blood vessel formation
    • Cataracts - high glucose levels can lead to sorbitol deposits in the lens
    • Haemorrhages
    • Microaneurysms
    • Exudate
    • Retinal detachment (slit lamp)
    • Laser scars
Laser eye surgery.jpg
Laser scars
Macular Oedema.jpg
Macular Oedema associated with hard exudates
Retinal Detachment.jpg
Retinal Detachment with Vitreous Haemorrhage

c. Eye movements

  • Test the movements of the eye for cranial nerve neuropathies by getting the patient to follow your finger and making an H-shape.
  • Ask the patient if they ever experience eye pain or double vision while doing so. Look for any movement the patient can't do as well as nystagmus (involuntary eye movements)
Eye2.png
Isolating the different eye muscles. Superior Oblique (CNIV), Lateral Rectus (CNVI). All others CNIII

d. Ears

  • Look for infection

e. Mouth

  • Dry mucous membranes
  • Candida infection
Angular_Cheilitis_wiki.JPG
Angular Stomatitis (Candida infection most common)

8. Chest

  • Look for:
    • Signs of infection
    • Mediastinal scar
  • Listen to apex

9. Abdomen

10. Urinalysis

11. Conclude

Thank the patient and offer assistance.

See Also

Type I Diabetes Mellitus
Type II Diabetes Mellitus

Citation

Cushing's Syndrome Image: From http://medlibes.com/entry/cushings-syndrome
Neuropathic Arthropathy Image: "Charcot arthropathy clinical examination" by J. Terrence Jose Jerome - Divergent Lisfranc’s Dislocation and Fracture in the Charcot Foot: A case report. Foot and Ankle Online Journal (FAOJ). 1 (6): 3.. Licensed under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Charcot_arthropathy_clinical_examination.jpg#/media/File:Charcot_arthropathy_clinical_examination.jpg
Leg Cellulitis image - Ujb 98 at the English language Wikipedia [GFDL (www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons
Fat atrophy image - http://intranet.tdmu.edu.ua/data/kafedra/internal/vnutrmed2/classes_stud/en/med/lik/ptn/Internal%20medicine/4%20course/04.%20Novel%20methods%20of%20treatment%20of%20diabetic%20patients..htm
Fat hypertrophy image - http://intranet.tdmu.edu.ua/data/kafedra/internal/vnutrmed2/classes_stud/en/med/lik/ptn/Internal%20medicine/4%20course/04.%20Novel%20methods%20of%20treatment%20of%20diabetic%20patients..htm
Pulses image - http://intranet.tdmu.edu.ua/data/kafedra/internal/propedeutic_vn_des/classes_stud/en/med/lik/ptn/Nurse%20practice/3/leson_1_Organization%20of%20nurse%20post.htm
Capillary refill image - By Alex Miles, author's own
Lower Limb Dermatomes image - from http://moodle.unitec.ac.nz/mod/folder/view.php?id=235867&lang=mi_wwow
Laser scars image - "Fundus photo showing scatter laser surgery for diabetic retinopathy EDA09" by National Eye Institute, National Institutes of Health - http://www.nei.nih.gov/photo/eyedis/index.asp. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Fundus_photo_showing_scatter_laser_surgery_for_diabetic_retinopathy_EDA09.JPG#/media/File:Fundus_photo_showing_scatter_laser_surgery_for_diabetic_retinopathy_EDA09.JPG
Macular Oedema image - "Diabetic macular edema" by National Eye Institute, National Institutes of Health (photographer credit not given) - National Eye Institute photography page. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Diabetic_macular_edema.jpg#/media/File:Diabetic_macular_edema.jpg
Retinal Detachment image -"Slit lamp photograph showing retinal detachment in Von Hippel-Lindau disease EDA08" by National Eye Institute/National Institutes of Health - http://www.nei.nih.gov/photo/eyedis/index.asp. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Slit_lamp_photograph_showing_retinal_detachment_in_Von_Hippel-Lindau_disease_EDA08.JPG#/media/File:Slit_lamp_photograph_showing_retinal_detachment_in_Von_Hippel-Lindau_disease_EDA08.JPG
Eye Movements image - By Alex Miles, author's own
Angular Stomatitis image: "Angular Cheilitis" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -https://commons.wikimedia.org/wiki/File:Angular_Cheilitis.JPG#/media/File:Angular_Cheilitis.JPG