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.