The Diabetes Exam

Hello, my name is Dr Tom Brannigan. I'd like to do a diabetes exam on you, if that's ok. Ok. What's your name? I'm Luke. Luke. Nice to meet you Luke. Hello. It's a lukewarm 45 degrees. Could I get you to just lift up your t-shirt a little bit? And I'm just going to have a look at you from the end of the bed. Maybe you could pull up your shorts a little bit. Pull the leg up. First, remember the general observations that apply to any system. Apply these specifically to the diabetes exam. Is the patient well or unwell? Comment on the patient's alertness, as dehydration, hypoglycemia and hyperglycemia can affect consciousness level. Comment on their colour, noting especially acanthosis nigricans, which is darkened, thickened skin in the body folds. Comment on the patient's weight, in particular any signs of recent weight loss or gain. Note the patient's hydration status. Is the patient breathing comfortably or are they dyspneic? Note customised breathing if present. This is deep, laboured hyperventilation. Note any scars or bruises, especially around the abdomen or upper thighs, which can be secondary to insulin injection. Note any obvious endocrine phases, as certain conditions such as Cushing syndrome, acromegaly, Graves disease or haemochromatosis predispose patients to diabetes mellitus. Look for equipment or devices that are attached to or surrounding the patient, such as insulin pens, glucometer and strips or an insulin pump. Note any medications around the bed. Note the location of the patient and note any signs around the bed. As you approach the patient for closer inspection, check the axillae and neck for acanthosis nigricans. Offer to perform a lying and standing blood pressure to check for orthostatic hypotension. In practical terms, this is too lengthy a process to be done in an OSCE, unless it were the sole function of the OSCE. Visual acuity is not formally tested in a diabetes exam, so it is not necessary to use a snellen chart at 6 metres from the patient. You may use a pocket snellen chart to ensure that the patient can see adequately through each eye. A common complication of diabetes mellitus is visual impairment, due to cataracts or various retinal pathologies. The motor components of the 3rd, 4th and 6th cranial nerve are tested together. Make sure that the patient does not move their head and make sure to instruct them to inform you if at any point they see double. Using the ophthalmoscope, assess for rubeosis, cataracts and retinal pathologies in each eye. Ask the patient to stick out their tongue and look at their mucous membranes to assess hydration status. Perform a closer inspection of the abdomen and the upper thighs for bruising, fat atrophy or hypertrophy secondary to insulin injections. Palpate over these areas to feel for any lumps that may not be apparent on inspection. Perform a closer inspection of the legs. Inspect between each of the toes for breaks in the skin. Make sure to lift up each leg to check for ulcers on the heels. Palpate for temperature along the legs using the dorsum of your fingers. Palpate any erythematous areas for warmth with the dorsum of your fingers. Palpate the peripheral pulses of the lower limb. Start with the femoral artery. Move on next to the popotial artery. Palpate for posterior tibialis between the medial malleolus and heel. Move on to dorsalis pedis. This is located lateral to extensor hallucis longus tendon, just distal to the dorsal surface of the nubicular bone. Check capillary refill time. This is normally less than 3 seconds. Just so you know what I'm about to do, this is what I'm going to put on your leg. Can you feel that? I can. And how does it feel to you? It's soft. So I'm just going to touch that at various points around your legs. If you could just say yes when you feel the cotton bud touching it, and let me know if it feels different on the left than the right. Okay. Okay, now just close your eyes. Test for light sensation of each dermatome bilaterally. After every two to three dermatomes, ask if the left and the right feel the same. If sensory loss is detected, spend more time around that dermatome to define its borders. Yes. Okay. I'm going to go through the same again. I'm only going to use this slightly sharper end, just so you know what it feels like. Did you feel that? I did. And how did it feel? Pointy. Okay, so I'm going to just touch it on the same spot. So I guess you'd close your eyes again. Just let me know if you feel it. Test for sharp sensation of each dermatome bilaterally. Yes. After every two to three dermatomes, ask again if the left and the right feel the same. Yes. If sensory loss is detected, spend more time around that dermatome to define its borders. Yes. There's one other type of sensation that I want to check. So this is just a little plastic filament. So just tell me if you can feel this. The characteristic sensory loss in diabetes is in a stopping pattern. Test for vibration sensation using a 128 Hz tuning fork. The next thing I'd like to check is your vibration sensation. So just so you know what it's going to feel like. Can you feel this? Yes. Can you feel when it stops? After testing for vibration sensation at the sternum, place the vibration tuning fork on the bone of one of the distal interphalangeal joints. If the patient does not feel the vibration, move to a more proximal bony prominence, such as the metatarsal interphalangeal joints, the medial malleolus, or the knee. Ask the patient if they can feel the vibration, and to tell you when it stops. So the next thing I'm going to do is check for your proprioception, so it's whether or not you can tell where things are in space. So I'd like you to close your eyes, and what I'm going to do is move your toe up and down. I want you to tell me, is it up or is it down? To test proprioception, take the distal interphalangeal joint of one of the patient's toes. Hold the side of the toe and move it up and down, asking the patient to tell you whether you stop with it pointing upwards or downwards. Up. Down. Up. Okay. We'll do the same on the other side. So I'll just start to sink this toe again. Up versus down. So just let me know. What's this? Up. Down. Up. Next, check the reflexes in the lower limb. So I'm going to just check your reflexes around the leg as well. Prior to testing them, explain to the patient what you are about to do. Let me take the full weight. You don't have to try and support yourself. Ensure that the limb being tested is fully relaxed before attempting to elicit reflexes. Some patients may need to be told multiple times before they fully relax. When checking the patellar reflex, observe the quadriceps muscles for a flicker of movement. So now I'm going to put the heel of this leg onto the shin of this leg. It's a little bit uncomfortable, but try and find a spot that's comfy for you. Is that alright? That's okay. When checking the Achilles reflex, observe gastrocnemius for a flicker of movement. If you have difficulty eliciting a reflex, ensure that the patient is fully relaxed. Reposition yourself and try again. If you are still unable to elicit the reflex, employ a gendristics reinforcement manoeuvre and try one more time. Report your findings at the end of this. That's great. Hey Luke. Thanks very much for that. No problem. Thank you. You're welcome. Thank you. You're welcome.