CLINICAL EXAMINATION OF THE DIABETIC PATIENT

GENERAL EXAMINATION

Weight:Weight loss in insulin deficiency and obesitiy in Type 2 diabetes.Check height and calculate the BMI. General examination:ill looking?,consious? Is the patient in any respiraory distress?Tachynoea? Some may have Kussmauls respirations- DKA.Dry mucous membranesdehydration in DKA and HHS

Hands:

Dupuytren's contracture is common in diabetes Carpal tunnel syndrome is common in diabetes and presents with wrist pain radiating into the hand. Trigger finger (flexor tenosynovitis) may be present in people with diabetes. It is noninfectious inflammation of the flexor tendon sheath of the finger (or thumb). Patients often complain of pain and a sensation of "snapping" when they flex the affected digit; the pain radiates into the palm or the distal finger

Limited joint mobility (sometimes called 'cheiroarthropathy') This is the inability to extend (to 180) the metacarpophalangeal or interphalangeal joints of at least one finger bilaterally. The effect can be demonstrated in the 'prayer sign'. It causes painless stiffness in the hands, and occasionally affects the wrists and shoulders

Pebbled knuckles (or Huntley papules) are multiple minute papules, grouped on the extensor side of the fingers and on the knuckles.This arises as a result of thickening of the skin on the dorsum of the hand.

Pulse: Tachycardia occurs in DKA and HHS

Blood pressure: Hypotension in DKA and HHS Neck: Carotid pulses and bruits,Thyroid enlargement. Head:Cranial nerve palsies,ptosis,eye movements Examine the eyes for lens opacities,visual acuity and do fundoscopy

Insulin Injection sites:Anterior abdominal wall Upper thighs/buttocks ,Upper outer arms. Inspect for bruising, Subcutaneous fat deposition (lipohypertrophy) ,Subcutaneous fat loss (lipoatrophy),erythema, infection (rare) Abdomen:Hepatomegaly.Due to fatty infiltration in the liver(NAFLD). Type 2 DM is a risk factor.NAFLD may lead to cirrhosis Lower limbs:Muscle wasting,sensory abnormalityby testing for sensation, tendon reflexes and peripheral pulses .

DERMATOLOGICAL MANIFESTATIONS OF DIABETES MELLITUS.

Diabetes mellitus can be complicated by variety of cutaneous manifestations. Good metabolic control may prevent some of these manifestations and may support cure. Almost all diabetic patients eventually develop skin complications from the long-term effects of diabetes mellitus on the microcirculation and on skin collagen.

Patients who have had diabetes for many years tend to develop the most devastating skin problems. However, problems can also develop in the short term, as insulins and oral hypoglycemic drugs can also have dermal side effects. Furthermore, diabetesrelated cutaneous lesions may also serve as a port of entry for secondary infection.

Poor and delayed wound healing and skin ulceration. Insulin signaling supports normal skin proliferation, differentiation, and maintenance, and a lack of insulin may lead to impaired wound healing.

Periungual telangiectasia:They appear as red, dilated, capillary veins bordering the base and lateral aspects of the nail plate. A prevalence up to 49% has been described in all diabetic patients. In diabetes, periungual telangiectasia is often associated with nail fold erythema, accompanied by fingertip tenderness and ragged cuticles.

Necrobiosis lipoidica: The initial lesions of NLD begin as well-circumscribed erythematous papules. Evolving radially, the sharply defined lesions have depressed, waxy, yellow-brown, atrophic telangiectatic centers through the underlying dermal vessels can be visualized. The periphery is slightly raised and erythematous. The pretibial region is the area typically affected. Ulceration occurs in up to 35% of cases. Women are affected more often than men. Patients with type 1 diabetes develop necrobiosis lipoidica at an earlier mean age than those with type 2 and those without diabetes.

Bullosis Diabeticorum (Diabetic bullae) This develops in approximately 0.5% of diabetic patients, but more often in those with type 1 diabetes, and more often in men and in patients with long-standing diabetes with peripheral neuropathy. It presents as asymptomatic bullae containing sterile fluid on a noninflamed base, usually arising spontaneously on the dorsa and sides of the lower legs and feet, sometimes on the hands or the forearms. The cause is unknown, and it is a diagnosis of exclusion.

Vitiligo Vitiligo vulgaris, or skin depigmentation, occurs more often in type 1 diabetic patients. From 1% to 7% of all diabetic patients have vitiligo vs 0.2% to 1% of the general population.

Lichen planus Clinically, lichen planus presents as polygonal erythematous flat lesions. Most often affected are the wrists, the dorsa of the feet, and the lower legs. Oral lichen planus presents as white stripes in a reticular pattern and may occur in some diabetic patients.

Scleroderma diabeticorum Scleredema diabeticorum is characterized by thickening of the skin of the posterior neck and upper back, occasionally extending to the deltoid and lumbar regions. A peau dorange appearance of the skin can occur, often with decreased sensitivity to pain and touch.It almost exclusively occurs in long-standing diabetes, is usually permanent, is not related to previous infection, and usually occurs in middle aged,overweight poorly controlled type 2 diabetes.

Acanthosis nigricans Acanthosis nigricans presents as hyperpigmented, velvety plaques in body folds. The dark color is due to thickening of keratin-containing superficial epithelium. The pathogenesis is most likely related to high levels of circulating insulin, which binds to insulin-like growth factor receptors to stimulate the growth of keratinocytes and dermal fibroblasts. Although the lesions are generally asymptomatic, they can be painful, malodorous, or macerated.

Granuloma annulare The cause is not known. The lesions are oval or ringshaped, with a raised border of skin-colored or erythematous papules. The size varies from millimeters to centimeters. The dorsa of the hands and arms are the areas usually affected.This skin manifestation has no direct association with diabetes but may be seen in some diabetics.

Diabetic dermopathy Diabetic dermopathy (ie, shin spots and pigmented pretibial papules) affects 7% to 70% of all diabetic patients and has been termed the most common cutaneous finding in diabetes. It is usually noted as asymptomatic atrophic, scarred, hyperpigmented, finely scaled macules, which are usually bilateral but not symmetrically distributed.Lesions may also be found on the forearms, thighs, and lateral malleoli. Several studies found severe microvascular complications in patients with diabetic dermopathy, indicating a close association with a high risk of accelerated diabetes complications.

Yellow Skin and nails The possible cause of yellow skin and nails might be glycosylation end products. It is known that proteins which have a long turnover time, such as dermal collagen, undergo glycosylation and become yellow. Yellow skin is a common finding among patients with diabetes, probably best appreciated on the palms and soles because of sparse competition with melanocytic pigment in these areas

WHEREAS KERATIN OF THE EPIDERMIS IS ONLY PRESENT FOR ONE MONTH BEFORE BEING SHED, THAT OF THE NAIL PLATE MAY BE PRESENT FOR GREATER THAN A YEAR. THE PROTEIN- GLUCOSE REACTION PRESUMABLY CONTINUES
TO EVOLVE IN THE AGING NAIL RESULTING IN THE MOST YELLOW PIGMENT AT THE DISTAL ASPECT NAIL.

Insulin lipoatrophy and lipodystrophy. Lipoatrophy presents as circumscribed, depressed areas of skin at the insulin injection site 6 to 24 months after the start of therapy. Children and obese women are affected most often. It may be caused by lipolytic components in the insulin preparation or by an inflammatory process mediated by immune complex.

Other theories involve cryotrauma from refrigerated insulin, mechanical trauma due to the angle of injection, surface alcohol contamination, or local hyperproduction of tumor necrosis factor alpha from macrophages induced by injected insulin.

Lipohypertrophy clinically resembles lipoma and presents as soft dermal nodules at the site of frequent injections. Lipohypertrophy is regarded as a local response to the lipogenic action of insulin and can be prevented by rotation of the injection site