Examiners who are not ophthalmologists tend to underestimate the severity of retinopathy, which cannot be evaluated accurately unless the patients’ pupils are dilated.The dorsalis pedis and posterior tibialis pulses should be palpated and their presence or absence noted.If the respiratory rate and pattern suggest Kussmaul respiration, DKA must be considered immediately, and appropriate tests must be ordered.The funduscopic examination should include a careful view of the retina.Ask about the type of insulin being used, delivery system (pump vs injections), dose, and frequency. Of course, a full review of all medications and over-the-counter supplements being taken is crucial in the assessment of patients with type 1 DM.Patients using a pump or a multiple-injection regimen have a basal insulin (taken through the pump or with the injection of a long-acting insulin analogue) and a premeal rapid-acting insulin, the dose of which may be determined as a function of the carbohydrate count plus the correction (to adjust for how high the premeal glucose level is).Severe nocturnal enuresis secondary to polyuria can be an indication of onset of diabetes in young children.Thirst is a response to the hyperosmolar state and dehydration.
Measurement of the pulse is important, in that relative tachycardia is a typical finding in autonomic neuropathy, often preceding the development of orthostatic hypotension.
A diabetes-focused physical examination includes assessment of vital signs, funduscopic examination, limited vascular and neurologic examinations, and foot examination.
Other organ systems should be assessed as indicated by the patient’s clinical situation.
Fatigue and weakness may be caused by muscle wasting from the catabolic state of insulin deficiency, hypovolemia, and hypokalemia. Blurred vision results from the effect of the hyperosmolar state on the lens and vitreous humor.
Glucose and its metabolites cause osmotic swelling of the lens, altering its normal focal length.
(See Diabetic Foot and Diabetic Foot Infections.) In new cases of diabetes, physical examination findings are usually normal.