Remember hand

hygiene before and

after every patient
contact

Diabetes Examination
General Appearance/Inspection
All examinations begin with a general inspection of the patient and their immediate surroundings. This is done
from the end of the bed.
Weight/Body mass index
Pigmentation changes, e.g. bronze, vitiligo/other stigmata of auto-immune conditions
Muscle wasting
Features of Cushings syndrome
o Weight gain, especially in the face, supraclavicular region, upper back, and torso (central obesity)
o Skin changes
acne
dry skin
hyperhidrosis
purple/red striae
easy bruising
poor wound healing
o Hirsutism and baldness
o Proximal muscle weakness
Features of myotonic dystrophy, acromegaly, pregnancy
Hydration status
Bedside
o Insulin pens, blood lancets, glucometer, blood glucose diary
o Glucose sweets/drinks
o Diabetic dietary supplements
Closer Inspection
Mucous membranes
Injection sites lipoatrophy and lipodystrophy
Skin changes acanthosis nigricans and skin tags evidence of insulin resistance
Pulps of fingers dots consistent with capillary blood sampling
Sub-cutaneous infusion pump
Cardiovascular Examination
Perform complete cardiovascular exam as previously described.
Eye exam

Visual acuity

Inspection
o Cataracts
o Rubeosis iridis

Fundoscopy
Non Proliferative Retinopathy
Dot and blot haemorrhages
Micro-aneurysms
Hard and soft exudates

Proliferative Retinopathy
New vessel formation
Vitreal haemorrhage
Retinal detachment
Laser scars

Lower Limbs
INSPECTION

Hair loss
Necrobiosis lipodica
Muscle wasting
Ulcers
Amputations/scars relating to revascularization surgery
Charcot joints

PERIPHERAL PULSES
Always compare one side with the other

Dorsalis Pedis - first intermetatarsal space, lateral to extensor hallicus longus tendon

Posterior Tibial - halfway between medial malleolus and heel

Popliteal - palpable behind knee in semi-flexed position

Femoral - mid inguinal point halfway between pubic symphysis and anterior superior iliac spine

PERIPHERAL SENSATION

Light touch

o Use cotton wool to test for light touch. Initially touch the anterior chest wall [normal area]; this is to
demonstrate to the patient how it feels.
o Ask the patient to close their eyes and test in each dermatome comparing right with left.
o Ask patient to tell you when they feel something.

Pain

o Using a sharp object touch the patients anterior chest wall [normal area], this is to demonstrate to the
patient how it feels sharp.
o Ask the patient to close their eyes and test in each dermatome comparing right with left. Ask patient if
they can feel object and if it feels sharp or dull.

o Map out any area of dullness. Always do this by moving from area of dullness to the area of normal
sensation.

Vibration

o The base of a vibrating tuning fork is placed on the anterior chest wall. It should be explained to the
patient that it is the sensation of vibration and not cold or touch which is being detected.
o The base of the vibrating tuning fork is then placed on the dorsum of the terminal phalanx. The patient is
asked can they feel it vibrate and to indicate when vibration stops.
o They are then asked to repeat this with their eyes closed. Stop the tuning fork vibrating by touching it and
the patient should be able to say exactly when this occurs.
o Compare one side with the other.
o Should vibration sense be lost or impaired distally then the tuning fork should be moved proximally
[Lateral malleolus, upper part of tibia, iliac crest, costal margin] in order to establish the level at which it
is normally appreciated.

Proprioception

o Grasp the distal phalanx from the sides and move it up and down to demonstrate these positions. Then ask
the patient to close the eyes while these manoeuvres are repeated. Normally movement through even a few
degrees is detectable, and should be reported correctly.
o If there is an abnormality, proceed to test the ankles and knees similarly.
Dermatomes

REFLEXES
1. Remember to use the whole length of the patella hammer.
2. Let the hammer swing.
3. Make sure the patient is resting comfortably.
The reflexes can be recorded as follows:
o 0 Absent reflexes
o + Reduced reflexes
o ++ Normal reflexes
o +++ Exaggerated reflexes
o ++++ Exaggerated reflexes and clonus
Knee jerk [L3, L4]
Slide the left arm under the knees so they are slightly bent and supported. The tendon hammer is allowed to fall
on to the infrapatellar tendon. Contraction of the quadriceps causes extension of the knee.
Ankle jerk [S1, S2]
Have the foot in the mid-position at the ankle with the knee bent and thigh externally rotated. The hammer is
allowed to fall on the Achilles tendon. The normal response is plantar flexion of the foot with contraction of the
gastrocnemius muscle.
Reinforcement
o For the legs, ask the patient to link hands across his chest and pull one against the other, as you swing the
hammer. (Jendrassik manoeuvre).