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8/13/2019 Clinical Examination of a Diabetic Patient Er
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CLINICAL EXAMINATION OF
THE DIABETIC PATIENT
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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 membranes-
dehydration in DKA and HHS
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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; thepain radiates into the palm or the distal finger
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Limited joint mobility (sometimes called
'cheiroarthropathy')
This is the inability to extend (to 180) themetacarpophalangeal 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
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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.
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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
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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 inthe liver(NAFLD). Type 2 DM is a risk factor.NAFLD
may lead to cirrhosis
Lower limbs:Muscle wasting,sensory abnormalitybytesting for sensation, tendon reflexes and
peripheral pulses .
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DERMATOLOGICAL
MANIFESTATIONS OF
DIABETES MELLITUS.
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Diabetes mellitus can be complicated by varietyof 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 ofdiabetes mellitus on the microcirculation and on
skin collagen.
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Patients who have had diabetes for many
years tend to develop the most devastatingskin problems. However, problems can also
develop in the short term, as insulins and
oral hypoglycemic drugs can also have
dermal side effects. Furthermore, diabetes-related cutaneous lesions may also serve as
a port of entry for secondary infection.
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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.
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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.
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Necrobiosis lipoidica:
The initial lesions of NLD begin as well-circumscribed
erythematous papules. Evolving radially, the sharplydefined 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 isthe 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.
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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.
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Vitiligo
Vitiligo vulgaris, or skin depigmentation, occurs more
often in type 1 diabetic patients. From 1% to 7% of alldiabetic patients have vitiligo vs 0.2% to 1% of the
general population.
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Lichen planus
Clinically, lichen planus presents as polygonal
erythematous flat lesions. Most often affected are thewrists, 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.
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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 dorangeappearance of the skin can occur, often
with decreased sensitivity to pain and touch.It almost
exclusively occurs in long-standing diabetes, is usuallypermanent, is not related to previous infection, and
usually occurs in middle aged,overweight poorly
controlled type 2 diabetes.
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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.
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Granuloma annulare
The cause is not known. The lesions are oval or ring-
shaped, 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 somediabetics.
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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 notsymmetrically 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 ahigh risk of accelerated diabetes complications.
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Yellow Skin and nails
The possible cause of yellow skin and nails might
be glycosylation end products. It is known thatproteins 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 bestappreciated on the palms and soles because of
sparse competition with melanocytic pigment in
these areas
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WHEREASKERATINOFTHEEPIDERMISISONLYPRESENT
FORONEMONTHBEFOREBEINGSHED, THATOFTHENAIL
PLATEMAYBEPRESENTFORGREATERTHANAYEAR. THEPROTEIN- GLUCOSE REACTION PRESUMABLY CONTINUES
TOEVOLVE INTHEAGINGNAILRESULTING INTHEMOST
YELLOWPIGMENTATTHEDISTALASPECTNAIL.
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Insulin lipoatrophy and lipodystrophy.
Lipoatrophy presents as circumscribed, depressed areas
of skin at the insulin injection site 6 to 24 months after thestart 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.
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Other theories involve cryotrauma from refrigerated
insulin, mechanical trauma due to the angle ofinjection, surface alcohol contamination, or local
hyperproduction of tumor necrosis factor alpha from
macrophages induced by injected insulin.
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Lipohypertrophy clinically resembles lipoma and
presents as soft dermal nodules at the site offrequent injections. Lipohypertrophy is regarded as
a local response to the lipogenic action of insulin
and can be prevented by rotation of the injection
site
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