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.