The Diabetes Exam

Summary

In this detailed clinical demonstration, Dr. Tom Branan performs a comprehensive diabetes examination on a patient named Luke. The video covers general observations, vision checks, hydration assessment, inspection and palpation of the abdomen, thighs, legs, and feet, as well as vascular and neurological evaluations. Dr. Branan systematically assesses peripheral pulses, sensory perception, vibration, proprioception, and reflexes, while providing clear instructions and explanations throughout. The demonstration highlights common diabetes-related complications, including neuropathy, foot ulcers, and visual impairments, offering a thorough, step-by-step guide for clinicians to conduct a complete diabetes-focused physical assessment.

Takeaways

• 😀 Begin with general observations: assess patient’s overall wellness, alertness, color, hydration, and breathing.
• 😀 Look for signs of endocrine disorders or complications that may predispose to diabetes, such as Cushing’s syndrome, acromegaly, Graves’ disease, or hemochromatosis.
• 😀 Inspect the patient for scars, bruises, or signs of insulin injections, particularly on the abdomen and upper thighs.
• 😀 Check for the presence of medical devices and medications, such as insulin pumps, glucometers, and strips.
• 😀 Conduct a visual assessment: ensure adequate vision, test cranial nerves III, IV, and VI via eye movements, and inspect for cataracts or retinal pathology.
• 😀 Examine mucous membranes and tongue for hydration status and overall oral health.
• 😀 Perform a detailed lower limb and foot examination: inspect skin, toes, heels, temperature, pulses, and capillary refill.
• 😀 Assess sensory function using light touch, sharp sensation, vibration (128 Hz tuning fork), proprioception, and monofilament testing to detect diabetic neuropathy.
• 😀 Evaluate reflexes including patellar and Achilles, ensuring proper limb relaxation and using reinforcement maneuvers if needed.
• 😀 Systematic, step-by-step examination is essential for early detection of diabetic complications and ongoing patient management.

Q & A

What is the initial step Dr. Tom Branan takes in the diabetes examination?

Dr. Branan begins by introducing himself, confirming the patient's name, and requesting the patient to lift their T-shirt and shorts slightly to allow for visual inspection.

Why does Dr. Branan emphasize observing the patient's general condition during the exam?

General observations help assess whether the patient is well or unwell, noting alertness, color, weight changes, hydration, breathing, and the presence of scars or bruises, all of which can indicate complications of diabetes.

What specific skin condition is highlighted as important in a diabetes exam?

Acanthosis nigricans, which appears as darkened, thickened skin, often around the neck or axilla, is noted because it can indicate insulin resistance.

How does the doctor check for visual complications related to diabetes?

Dr. Branan tests vision using a pocket vision chart, performs eye movement tests to assess cranial nerves III, IV, and VI, and examines the eyes with an ophthalmoscope for cataracts, retinopathy, or other retinal pathologies.

What areas of the body are inspected for insulin injection-related changes?

The abdomen and upper thighs are closely inspected and palpated for bruising, fat atrophy, or hypertrophy that can result from repeated insulin injections.

Which lower limb assessments are performed during the exam?

The doctor inspects and palpates the legs and feet for skin integrity, temperature, ulcers, and peripheral pulses (femoral, popliteal, posterior tibialis, dorsalis pedis), and also checks capillary refill time.

How is sensory function assessed in diabetic patients during this exam?

Sensory function is tested for light touch, sharp sensation, vibration using a 128 Hz tuning fork, and proprioception using movement of the toes, often focusing on a stocking pattern typical in diabetic neuropathy.

Why are reflexes checked in the lower limbs during a diabetes exam?

Reflexes, including the patellar and Achilles reflexes, are tested to assess for peripheral neuropathy and ensure proper nerve function in the lower limbs.

How does Dr. Branan ensure accurate sensory testing results?

He asks the patient to close their eyes, tests each dermatome bilaterally, compares left and right sensations, and if sensory loss is detected, he further delineates the affected area.

What practical tips are given for checking blood pressure in a diabetes exam?

Dr. Branan mentions offering lying and standing blood pressure measurements to check for orthostatic hypotension, though this is noted as a time-consuming step not usually done unless necessary.

What signs or equipment around the patient are observed before the physical exam?

The doctor notes devices like insulin pens, glucometers, insulin pumps, medications, and any environmental signs indicating the patient's diabetes management and current condition.