Once you have completed the history taking, you will know which system to examine more thoroughly i.e. the system that correlates with the primary or chief complaint. For example, if the chief complaint was numbness in the feet, then a thorough examination of the lower limbs would be the next logical step.
For the purpose of this blog, I'll list out the things required for examination in general. You may tailor the examination requirement based on the patient you've clerked in the exam.
General Examination:
1. GCS - always good to assess this. An alternative is the orientation to time/ place/ person assessment. The patient's mental state is an important first assessment for a diabetic patient as such patients are prone to cerebral ischemia, neuroglycopenia, hyperglycemic complications e.g. HHS and even vascular-related neurocognitive impairments.
2. If the patient has trouble remembering many facts during history taking, you may want to offer to do a Mini Mental State Examination (MMSE) at the end of the presentation to identify presence of and severity of cognitive impairment or dementia at the end of the patient's examination (however, this will not be possible in the real exam setting due to time constraints).
3. General appearance - Acromegaly, Cushingoid, thyrotoxicosis as these conditions may predispose to development of DM or aggravate DM control. Also look out for skin changes e.g. pallor or sallow coloured skin to suggest presence of chronic kidney disease and rashes that may suggest presence of connective tissue disorders e.g. systemic lupus, psoriasis, systemic sclerosis etc. Do take note of the peripheral joints as well especially the fingers, toes and ankle regions for any deformities to suggest a chronic inflammatory arthropathy or gout. The earlier mentioned conditions may all be treated with steroids for a prolonged period of time resulting in hyperglycemia or steroid induced diabetes mellitus.
4. Accessories - intravenous drips, insulin syringe pumps, intravenous antibiotics, oxygen support, orthoses (ankle splints for foot drop or limb prosthesis), customised shoes for Charcot foot or walking aids. Also improtant to take note of presence of arteriovenous fistulas and dialysis catheters (internal jugular or femoral dialysisc atheters)
5. Eyes - at least a visual acuity assessment using a portable modified Snellen's chart and RAPD assessment for any retinal or optic disc abnormality. If there is RAPD detected, then the next assessment would be funduscopy for diabetic retinopathy if time permits.
6. CVS - look for displaced apex with murmurs, raised JVP and bibasal crepitations to indicate heart failure (coronary artery disase is a complication of long standing and uncontrolled DM)
7. Respi - examination of this system should be selective. Look briefly for evidence of fluid overload e.g. basal crepitations to suggest pulmonary oedema or stony dullness percussion note with reduced vocal resonance to suggest pleural effusion.
8. Peripheral pulses especially the distal pulses e.g. dorsalis pedis,/ posterior tibialis pulses. This would be more relevant if the patient reports claudication pain during history taking. Auscultation of the carotid arteries for any bruit to indicate stenosis is also important if time permits. Do take note that uncontrolled diabetes mellitus may accelerate atherosclerosis changes along major arteries.
9. Neurological examination - particularly the lower limbs. You may limit the neurological examination to information obtained during history taking. For example if the patient reports that he has history of right sided leg weakness, then perhaps it is sufficient to focus your neurological examination to the lower limbs only, while briefly screen through neurological examination of the upper limbs and cranial nerves. Conducting a full neurological examination as a routine assessment during long case examination can be challenging due to time constraints. The earliest sign of diabetic peripheral neuropathy is loss of vibration sense and loss of proprioception in the distal joints e.g. interphalangeal joints in the toes. Also look out for diabetic foot ulcers, calluses over bony prominences and trophic changes affecting the skin over the lower limbs which may strongly suggest presence of peripheral neuropathy.
10. Abdominal examination - look for signs of lipohypertrophy or lipoatrophy to suggest repeated insulin injections. This can usually be found at the periumbilical region. If found, it would be important to highlight this finding during the case presentation as it will impact treatment outcome. Patients that fail to rotate the insulin injection sites adequately will have the above changes occurring and this will impair optimal insulin absorption and affect adequacy of glucose control. Look for Tenchoff catheters over the anterior abdominal wall to suggest patient has ESRF and is undergoing CAPD. Also look renal transplantation scars to suggest a history of diabetic kidney disease (renal transplant scars are usually J shaped and located at either right iliac fossa or left iliac fossa regions). It is also possible that immunosuppressive therapy post organ transplant be the aetiology for diabetes mellitus in such a patient. Do consider palpating the abdomen for an abdominal aortic aneurysm as well.
11. Lastly, do steal some time to screen the patient's body for any cutaneous infections like carbuncles, furuncles. Look also for tinea infections affecting the skin flexures e.g. axillary, infra-mammary, groin area. In uncontrolled diabetics, skin infections may be extensive.
CCE
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