Diabetes History and Examination

Question 1

History of presenting complaint

Answer 1

-Can first present in hospital with diabetic ketoacidosis or type 2 from high dose corticosteroid
-Will be in referral letter but ask patient to describe using open question
-Direct questions re
=Symptoms of diabetes (tired/ weight loss/ thirsty/ polyuria/ Nocturia/ blurry vision/ infections/ tingling)
=Duration of symptoms (gradual slow onset/ acute type 1)
=Risk factors for diabetes (type 2= obesity, family history, type 1 autoimmune conditions)
=Existing cardiovascular disease and risk factors (hypertension, obesity, dyslipidaemia, smoking and family history)
=Screening questions for microvascular complications (kidneys/ eyes/ feet)

Question 2

General history for new patient with diabetes

Answer 2

-Past Medical History (gallstones/ pancreatitis for secondary cause, autoimmune disease for type 1)
-Family History (presenting at young age genetic)
-Drug History, allergies
-Social History
=Who do they live with at home, occupation, driving (DVLA), smoking, alcohol (pancreatitis) (important in hypoglycaemia)
-Systemic enquiry
=CVS
=RS
=GI
=UG/Reproductive history (NB especially in young women diabetes- poor glycaemic control associated with congenital malformation and miscarriage)
=CNS (symptoms)

Question 3

General history of patient with existing diabetes during hospital admission

Answer 3

-Likely to be associated with acute diabetes emergency e.g. DKA, HHS, hypoglycaemia, foot ulcer
-Sometimes a new presentation e.g. DKA, chance finding on routine testing, or ‘caused’ (steroid administration)
-Commonly diabetes control becomes a problem and/or poor control becomes apparent during a hospital admission for another problem

Question 4

Important questions to ask patient with existing diabetes

Answer 4

-When were they diagnosed?
-What type of diabetes do they have?
-What medication are they taking?
-Do they have any complications of diabetes?
-Have they had any hospital admissions with diabetes? (DKA)
-Social history/driving etc

Question 5

Background questions to ask patient with existing diabetes on hospital admission

Answer 5

-Blood glucose monitoring results
-Diet, lifestyle, weight, concordance with medication/side effects
-Insulin titration
-Hypoglycaemic awareness
-Driving regulations
-Diabetes complications – feet, kidneys, eyes
-Cardiovascular risk factors – BP, cholesterol, smoking

Question 6

Inspection of patient with diabetes

Answer 6

-Observation
=Weight loss/BMI
=Cushing’s (steroids) /Acromegaly (excess growth hormone)/Thyroid (type 1)
=Dehydration/Kussmaul breathing (DKA)
=Technology e.g. freestyle libre/insulin pump

-Hands
=Cheiroarthropathy (prayer sign cannot flatten fingers and palms), Dupuytren’s (contraction), carpal tunnel (tingling)

-Skin
=necrobiosis lipoidica (shins and calves, inflammation, type 1), vitelligo (autoimmune), acanthosis nigricans (pigmentation of skin, type 2), xanthelasma (dyslipidaemia)

Question 7

Examination of patient with diabetes

Answer 7

-Blood pressure and CVS examination
-Abdomen – hepatomegaly (fatty liver, metabolic complication)
-Insulin injection sites
=Bruising
=Lipohypertrophy (poor glycaemic control)
-Eye screen
=Cataracts (type 2)
=Retinal screening
-Foot screen (annually)
=Inspection
=Circulation - Peripheral pulses
=Sensation (tuning fork for neuropathy)
=Reflexes

Question 8

Key diabetes investigations

Answer 8

-HbA1c (long term marker for glycaemic control)
-U+E
-LFT
-Lipid profile (HDL)
-Urine ACR (microalbuminuria)
-+/- TFT, coeliac screen
-+/- anti GAD, IA2, ZNT8 antibodies; c-peptide (type 1)
-Rarely – ferritin, fructosamine (haemachromatosis, haemoglobinopathy)