Although the physical examination traditionally follows the health history, you’ll actually begin your examination during the history. For example, you’ll probably note the patient’s general appearance and speech almost immediately. Irritability, difficulty concentrating, and a fruity breath odor are all common signs of hyperglycemia that has progressed to DKA in a patient with undetected Type 1 diabetes.If you suspect that your patient has diabetes, pay particular attention to her vital signs, height and weight, skin, head and neck, heart and blood vessels, mental status, neurologic function, and kidneys and bladder. If you already know that your patient has diabetes, be sure to assess her for complications of the disease.

Vital Signs

After noting your patient’s general appearance, take her vital signs. Vital sign abnormalities may or may not appear in diabetes. If hyperglycemia isn’t severe, vital signs may be normal. If the patient’s hyperglycemia has progressed to DKA or HHNK syndrome, you may detect hypotension, a weak and rapid pulse, Kussmaul’s respirations (deep but rapid respirations characteristic of DKA) or shallow and rapid respirations characteristic of HHNK syndrome, and an elevated temperature. Hypotension and a weak, rapid pulse may be caused by dehydration that results from polyuria. Kussmaul’s respirations are a compensatory mechanism in which the patient’s lungs attempt to alleviate excessive acid buildup in the body caused by ketone formation. Shallow, rapid respirations result from hypovolemic shock caused by extreme polyuria. An elevated temperature may stem from dehydration, but it commonly occurs because of an underlying infection.

Long-standing, undetected diabetes may have caused enough blood vessel damage to result in hypertension or enough nerve damage to result in autonomic neuropathy. Autonomic neuropathy may cause a systolic blood pressure drop of more than 10 mm Hg when the patient changes position or a fixed heart rate that doesn’t change with inspiration or exercise.

You may find cardiovascular abnormalities if your patient’s diabetes hasn’t been diagnosed or if she’s having difficulty controlling her blood glucose levels with her prescribed treatment.Most cardiac abnormalities are detected during the health history and through diagnostic tests rather than during the physical examination. If your patient has peripheral vascular disease, you may find abnormal skin changes. When palpating the peripheral pulses, especially the pedal pulse, you may note a decreased or absent pulse.

To check arterial competence, have your patient elevate her legs while she moves her feet up and down. Then have her sit with her legs dangling, normal color should return to her legs in about 10 seconds. A slowly developing dusky color indicates arterial insufficiency

In a person with diabetes, the oral mucous membranes may appear dry because of dehydration. When inspecting the patient’s gums, you may find that they bleed easily and appear swollen-an indication of periodontal disease caused by glucose pooling. Patients with diabetes who practice poor oral hygiene and poor blood glucose control commonly have oral infections. For example, white patches on the tongue, palate, and buccal mucosa are signs of oral thrush. Many ulcers covered with a pseudomembrane and thick oral secretions are signs of Vincent’s angina (trench mouth).Hyperglycemia affects the eyes in many ways. It may alter visual acuity, making it difficult for the patient to read a Snellen chart. Ocular neuropathy impairs extraocular eye movements. Prolonged hyperglycemia may cause eye disorders such as xanthelasma (slightly raised, yellowish, well-defined plaques that appear along the nasal side of the eyelids), cataracts (opacities visible on or in the lens that take on various shapes and colors), and glaucoma (increased intraocular pressure). Prolonged hyperglycemia also may cause diabetic retinopathy-an abnormality of the retina detected by ophthalmoscopic examination .