To diagnose diabetic retinopathy, an ophthalmologist uses an ophthalmoscopic examination or fluorescein angiography. During an ophthalmoscopic examination, the ophthalmologist dilates the patient’s eyes with a mydriatic drug, such as atropine. This dilation permits viewing of the retina, retinal blood vessels, optic disc, macula, and other structures.The ophthalmologist uses fluorescein angiography to evaluate leaking or occluded retinal vessels. In this outpatient procedure, fluorescein dye is injected into an arm vein. Then the dye travels through the blood to different parts of the body, including the retinal capillaries. By using fluorescein dye and a fundus camera with filters, the ophthalmologist can better see the retinal blood vessels and determine if the patient has retinopathy and, if so, to what extent.

Before being diagnosed and eventually treated for their diabetes, some diabetics experience sight problems due to their disease. These problems may be blurry vision, difficulties to focus and sudden near- or farsightedness. These problems may also be present during the first months of treatment. This might cause unnecessary worry, but is something that occurs to many diabetics, and it is due to the high blood sugar levels, that affect the eyes’ lenses. It is important however that the patient, if he or she is already using contact lenses or glasses, doesn’t walk right away to the local eye care professional to try out new lenses to cure this unexpected problem. When the treatment sets in, and the blood sugar goes back to normal, so does the changes of the lenses, and the vision is very likely to become normal again.

Diabetes patients otherwise usually don’t have any trouble using contacts or glasses, since the disease rarely affect the eyes. Any type of contact lens, like soft lenses or extended-wear lenses, is not likely to cause any problems. It is important however to have regular contact with the eye care professional, to make sure that any eye problems will not return and become permanent.

Begin the review of body systems by asking your patient about her general well-being. Commonly, a patient with diabetes will say that she doesn’t feel as well as she used to, and she’ll attribute her fatigue and weakness to growing older.Ask your patient about her weight history. A recent weight loss that’s not attributed to diet or a recent illness is a typical symptom of diabetes, especially Type 1 diabetes. People with Type 2 diabetes are usually obese. No one is sure why. Some researchers speculate that obesity is a factor in the development of Type 2 diabetes because fat cells require more insulin per cell than nonfat cells do. This leads to substandard insulin production as the pancreas works overtime to meet the obese patient’s insulin demands. Other researchers believe that obesity is actually an early sign of Type 2 diabetes.

Ask your patient about any skin conditions. One common symptom is dry, itchy skin, which develops because of mild dehydration associated with hyperglycemia. The itchiness is caused by glucose pooling under the skin. Such pooling also creates an ideal environment for skin infections, another common complaint of patients with diabetes. Patients may also report skin discoloration and chronic skin conditions, such as ulcers that don’t heal.

Next, ask your patient about visual disturbances. As glucose levels rise, glucose molecules cause blood vessels in the eyes to become congested and vision to blur. If your patient has prolonged hyperglycemia, she may report that she has trouble reading. She also may tell you that she sees dark spots, rings around lights, or flashing lights. Find out how often she has her eyes examined, when she last had them examined, and whether an ophthalmologist performed the examination. A patient with diabetes requires frequent eye examinations because the disease is one of the major causes of new cases of blindness diagnosed each year. Because of the complexity of diabetic retinopathy, a common complication associated with diabetes, an ophthalmologist should perform all eye examinations on a patient with diabetes.

Ask your patient about any history of periodontal disease or oral infections. These problems are common in patients with diabetes because of glucose pooling in gum tissue, which leads to frequent infections and destruction of delicate oral tissues.

Diabetes is also a major risk factor for arteriosclerosis, so ask your patient if she has any of the signs or symptoms of cardiovascular or peripheral vascular abnormalities: heart problems, chest pain, shortness of breath, hypertension, elevated cholesterol and triglyceride levels, cold feet, pain that occurs with walking, or leg or foot ulcers. Arteriosclerosis that affects the cerebral arteries may cause the patient to report transient ischemic attacks-brief episodes of dizziness, loss of sight, slurred speech, or feelings of numbness or weakness in one arm or leg.

Neuropathy, which may occur because of excessive glucose coating of the nerves, results from prolonged hyperglycemia. History findings that suggest peripheral neuropathy include a pins­and-needles sensation, sharp stabbing pains, and numbness in the hands or feet. Some patients may report leg pain that occurs only at night and is relieved by walking. Complaints that suggest autonomic neuropathy include nausea and vomiting, abdominal bloating, and nocturnal diarrhea, all of which are typical signs and symptoms of gastroparesis.

Some patients may complain of dizziness when changing position (suggesting orthostatic hypotension), an irregular pulse rhythm, or a fixed heart rate despite exercise (suggesting an electrical dysfunction of the heart).

Prolonged hyperglycemia may also lead to diabetic nephropathy, which is usually well ad­vanced before the patient experiences any symptoms. Ask your patient whether she has ever been told that she has protein in her urine. Also, ask her if she has ever had urinary tract or kidney infections. If she has, take a detailed history of the infections including the frequency, signs and symptoms, and treatment.

Ask your patient about reproductive abnormalities. Sexual dysfunction, including loss of li­bido, commonly develops in patients with diabetes. Impotence may develop in men with diabetes because of both blood vessel disease and neuropathy caused by chronic hyperglycemia. Women with diabetes may report frequent vaginal infections.

Assessment

You can use a health history and physical examination in two distinct ways to investigate diabetes. When you suspect that a patient has the disorder, you can perform a health history and physical examination to discover the characteristic signs and symptoms and confirm your suspicion. When you already know that a patient has diabetes, you can use a health history and physical examination to help monitor the disease and uncover any complications.

Diabetes looks different in different patients. The signs and symptoms, the severity, and even the type of diabetes can vary. But one thing is always the same, hyperglycemia.

Any patient with diabetes has one or both of these problems. She either produces little or no insulin, or her body can’t use insulin effectively. As a result, she has difficulty metabolizing carbohydrates, fats, and proteins, so hyperglycemia develops.

To diagnose diabetes, a physician needs to determine if a patient has hyperglycemia. Depending on the patient’s history and her signs and symptoms, one of three tests may be performed. For a patient with the typical signs and symptoms of diabetes, such as polydipsia, polyuria, polyphagia, blurry vision, and unexplained weight loss, a physician can base the diagnosis on a single random blood glucose level of 200 mg/dl or more. If a patient doesn’t have the typical signs and symptoms of diabetes, the physician needs a fasting blood glucose level of 126 mg/dl or more to make the diagnosis. For a patient who is at risk for developing diabetes (for example, someone who has a family history of diabetes or who is obese) and who has a normal fasting blood glucose level, a physician will use the 2-hour oral glucose tolerance test. He’ll make a diagnosis of diabetes if an initial test and one follow-up test reveal blood glucose levels of 200 mg/dl or more.

Treating diabetes consists of keeping blood glucose levels as close to normal as possible, using a combination of medication, diet, exercise, and stress control. By closely monitoring blood glucose levels and keeping them as close to normal as possible, a patient can reduce the risks of acute and long-term complications. The acute life-threatening complications of diabetes include hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar nonketotic (HHNK) syndrome. Long-term complications, which develop because chronic hyperglycemia causes damage to organs and tissues, include nephropathy, cardiovascular disease, peripheral vascular disease, cerebral vascular disease, neuropathy, and retinopathy.

A chronic disorder, Type 1 diabetes results from a complete or partial lack of insulin. Without insulin, glucose can’t enter the cells. Thus, the cells starve while high levels of glucose remain in the bloodstream. The body, sensing a lack of glucose in the cells, tries to increase its availability by breaking down fat and protein sources and glycogen stores to produce glucose. In another attempt to compensate, the body secretes counterregulatory hormones (glucagon, epinephrine, growth hormone, and cortisol) to increase blood glucose levels. But without insulin, these increases in glucose only contribute further to hyperglycemia.When the amount of glucose filtered by the kidneys surpasses the amount the kidneys can reabsorb, glucose appears in the urine. The glucose acts as an osmotic diuretic, causing the patient to produce increased amounts of urine. Elevated blood glucose levels also increase the osmotic pull of the blood, which causes water to move from the cells in the tissues into the bloodstream. This intracellular dehydration, along with the dehydration caused by increased urination, produces excessive thirst. Because the cells lack the glucose they need for energy, the person is continually hungry.

As the person burns fat and proteins for energy, fatigue and weight loss result. As body fats continue to break down, toxic levels of ketones are produced. Ketones can’t be used efficiently as energy, and as they accumulate in the blood, the pH drops, and metabolic acidosis develops. As the kidneys filter ketones, ketonuria develops. Insulin replacement is necessary to prevent DKA. The signs and symptoms of DKA include nausea, vomiting, electrolyte imbalances, a fruity breath odor, weight loss, and muscle wasting. Without treatment, DKA can progress to coma and death.

After being diagnosed with Type 1 diabetes, many patients experience a remission during which little or no insulin therapy is needed to control blood glucose levels. This honeymoon period can last up to a year, but once it ends, blood glucose levels rise, and insulin requirements increase.

Even when the disease is treated with exogenous insulin, it progresses, producing long-term complications. These complications can be classified as microvascular, macrovascular, and neuropathic. Microvascular complications include retinopathy, which can lead to blindness, and nephropathy, which can lead to renal failure. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Neuropathies can lead to conditions including impotence and a loss of sensation in the arms and legs. Among patients with Type 1 diabetes, renal disease is the most common cause of death, followed by cardiovascular disease.

If your patient has already been diagnosed with diabetes, you’ll need to ask some additional questions about her regimen. Specifically, you should ask about her medication, diet, exercise, and monitoring techniques.

Insulin and other drugs used to control diabetes lower blood glucose levels, putting patients at risk for hypoglycemia. Inappropriate diet and excessive exercise can also cause hypoglycemia. Ask your patient about the frequency of her hypoglycemic episodes and any signs or symptoms. Although hypoglycemic signs and symptoms may vary from patient to patient, the most common ones include headache, tremors, difficulty concentrating, drowsiness, irritability, anxiety, weakness, cold and clammy skin, light-headness, difficulty talking, and rapid heartbeat. If left uncorrected, hypoglycemia can lead to seizures and coma. Find out what kind of treatment your patient has received for hypoglycemia and how she has responded. Also, ask her if she can identify the cause of each episode . This information will help you evaluate your patient’s compliance with her regimen and her understanding of hypoglycemia. It may also lead to a change in the regimen.

Hyperglycemia may develop when your patient encounters stress and unavoidable changes in her daily life. Find out how much she understands about hyperglycemia and its two emergency complications, DKA and HHNK syndrome. Ask her about the frequency and severity of hyperglycemia, the signs or symptoms she experiences, any treatment she has received, and any changes made in her treatment plan. Frequent treatment for hyperglycemia may mean that she isn’t complying with her treatment plan or that it’s ineffective. To help her, explore the reasons for her hyperglycemia. Also, ask her if she understands sick-day rules and urine ketone testing. Illness is a common cause of hyperglycemic emergencies.

Finally, ask your patient if she has any concerns about her treatment plan. Her answers will help you and other members of the health care team identify potential problems and redesign a treatment plan that best fits her needs.

Begin the health history by gathering biographical information about your patient. If you suspect she has diabetes, make sure you note her age, ethnic group, and living arrangements.

Your patient’s age at the time of diagnosis provides a clue to the type of diabetes. Type 1 diabetes usually begins in early adolescence, Type 2, after age 35. Use caution, however; a patient over age 35 can be diagnosed with Type 1 diabetes, and a child can be diagnosed with Type 2 diabetes.

A person’s ethnic group may be a risk factor for diabetes. Mexican-Americans, Native Americans, and African-Americans have a higher rate of diabetes than those in other groups.

Whether a person lives alone has nothing to do with the disease process, of course, but it may have a lot to do with disease management. A spouse or partner who cooks for the patient can have a tremendous impact on the dietary aspect of diabetes treatment. And a spouse or partner can also provide much needed emotional support as the patient undergoes lifestyle changes to control her blood glucose levels.

Chief Complaint

Common chief complaints include polyuria, polydipsia, polyphagia, and weight loss. With diabetes, the patient feels constantly hungry because the glucose that usually feeds body cells remains in the blood. Excessive urination occurs as the kidneys try to eliminate the glucose from the blood. As glucose leaves the body through urine, the body loses water, which results in dehydration and thirst. Weight loss develops as cells are deprived of their main energy source-glucose.

Polyuria, polydipsia, and polyphagia may be pronounced in patients with Type 1 diabetes because the loss of insulin occurs abruptly. These signs can also develop in Type 2 diabetes, but because the loss of insulin occurs more slowly, they’re usually milder and are commonly over­looked. Other symptoms include fatigue and weakness.

In many cases, Type 2 diabetes goes undetected for many years. Therefore, a patient’s chief complaint may result from a complication of diabetes rather than the diabetes itself. Complaints of visual disturbances, neurologic impairment, cardiovascular dysfunction, or frequent infections should alert you to question the patient more closely about signs and symptoms of diabetes.

Progression of Type 2 Diabetes

In a patient with Type 2 diabetes, insulin loses its ability to inhibit glucose production, and beta cells are exposed to elevated blood glucose levels. This constant exposure to insulin leaves the beta cells unable to respond to hyperglycemia.

Peripheral insulin resistance occurs when the number of available insulin receptors in muscle and fat cells decreases. This results in higher blood glucose levels, progressively increasing the person’s requirement for insulin secretion. To reseverse the process, the person can lose weight, and to reduce blood glucose levels, she can take oral antidiabetic drugs. If these drugs, in conjunction with weight loss, don’t work effectively, the person may need insulin. She also may need insulin when she’s acutely ill or under stress.

Although the person has high blood glucose levels, she still produces enough insulin to pre vent DKA. However, she may lose fluids and electrolytes-losses that can lead to HHNK syndrome.

People with Type 2 diabetes may experience the same long-term complications as those with Type 1 diabetes. However, they’re particularly at risk for heart disease-the most common cause of death among patients with Type 2 diabetes. The hyperinsulinemia associated with Type 2 diabetes may be an important risk factor in the develop­ment of hypertension, abnormal lipid levels, and atherosclerosis.

Syndrome X is the combination of insulin resistance, hypertension, low high-density lipoprotein cholesterol levels, and increased very-low­density lipoprotein cholesterol levels. By the time most patients are diagnosed with Type 2 diabetes, they’ve had syndrome X for many years. The combined abnormalities of this syndrome increase the chances of angina, myocardial infarction, cerebrovascular accident, and peripheral vascular disease in patients with Type 2 diabetes.