Diabetes - Examination

Question 1

What general observations should be noted in a patient with diabetes?

Answer 1

Weight loss in insulin deficiency
Obesity in type 2 diabetes
Mucosal candidiasis
Dehydration - dry mouth, reduced tissue turgor
Air hunger - Kussmaul breathing in ketoacidosis

Question 2

What should be examined for in the hands of a diabetic patient?

Answer 2

Dupuytren's contracture
Carpel tunnel syndrome 
Trigger finger/ thumn
Limited joint mobility
Wasting of small muscles 
Sensory abnormality (test dermatomes)

Question 3

After hands, what is examined next in the diabetic patient?

Answer 3

Look at the skin, specifically for:

• pigmentation
• Necrobiosis lipoidica (can be found on the forearm or shins)
• Granuloma annulare
• Vitiligo (autoimmune)

After skin, check the BP and examine the axilla - look for acanthosis nigricans

Question 4

What should be examined for in the neck?

Answer 4

Carotid pulses
Bruits
Thyroid enlargement (goitre or nodular)

Question 5

What would you look for in the face and eyes of a diabetic patient?

Answer 5

Head: xanthelasma (hyperlipidaemia), cranial nerve palsy/ eye movements, ptosis

Eyes: visual acuity, cataracts/ lens opacity, fundoscopy (diabetic retinopathy)

Question 6

What are you looking for when you examine the insulin injection sites of a patient with diabetes?

Answer 6

Ask the patient where they inject their insulin and pay particular attention to:

Bruising
Lumps (lipodystrophy)
Subcutaneous fat deposition (lipohypertrophy) 
Subcutaneous fat loss (lipoatrophy) 
Erythema 
Infection

Question 7

You next move on to the legs. What features are you looking for?

Answer 7

Muscle wasting (diabetic amyotrophy) 
Sensory abnormality 
Granuloma anulare 
Hair loss
Tendon reflexes 
Necrobiosis lipoidica

Question 8

You finish with the patients feet. What are you examining for?

Answer 8

Inspection - callus, ulcers, Charcot neuropathy, funal infection)
Circulation - peripheral pulses, temperature
Neurology - light touch, pain, proprioception, reflexes

Question 9

Summarise the examination sequence in a diabetic patient?

Answer 9

General inspection/ observation

1) Hands
2) Skin
3) BP
4) Axilla
5) Neck
6) Head
7) Eyes
8) Insulin injection sites
9) Abdomen
10) Legs
11) Feet

Question 10

What is granuloma annulare?

Answer 10

Granuloma annulare is an uncommon skin condition, which most often affects children and young adults but can occur at any age. It is twice as common in
women as in men. The reason for this is unknown.

It usually presents as groups of small firm bumps in the skin which come together to form a characteristic ring shaped (annular) patch. These typically
occur on only one or two sites of the body, often overlying bony areas such as the back of the hands, the feet, elbows or ankles.

Question 11

What causes granuloma annulare?

Answer 11

Granuloma annulare is caused by inflammation in the deep layer of the skin.

The reason this reaction occurs is not known.
Granuloma annulare is harmless, does not affect general health, is not infectious or contagious and is not due to allergies. Some types of granuloma
annulare have been linked with diabetes, but this is very uncommon.