• Enquire about erectile dysfunction in men
• Ask about postural hypotension, sweating, diarrhoea and vomiting in
10.5 Causes of secondary diabetesa
Cause of diabetes Examples Clinical features
Pancreatic disease Pancreatitis Abdominal pain
Trauma/pancreatectomy Surgical scar
Cystic fibrosis Chronic cough, purulent sputum
Haemochromatosis Skin pigmentation (‘bronze diabetes’)
Endocrinopathies Acromegaly, Cushing’s syndrome p. 202
Drugs Glucocorticoids (e.g. prednisolone)
Antipsychotics (e.g. olanzapine)
Features of Cushing’s syndrome (see Fig. 10.11)
Immunosuppressants (e.g. ciclosporin, tacrolimus) Gum hypertrophy may be seen with ciclosporin use
Pregnancy Gestational diabetes may develop in the third trimester Gravid uterus
Glucokinase deficiency Glucokinase deficiency is present from birth with
Based on classification by the American Diabetes Association.
The physical examination • 207
Up to 40% of people with diabetes have peripheral neuropathy and
40% have peripheral vascular disease, both of which contribute
to a 15% lifetime risk of foot ulcers (Fig. 10.16).
Early recognition of the ‘at-risk’ foot is essential. There are
• Neuropathic: neuropathy predominates but the major
• Neuroischaemic: reduced arterial supply produces
ischaemia and exacerbates neuropathy.
Infection may complicate both presentations.
• Look for hair loss and nail dystrophy.
• Examine the skin (including the interdigital clefts) for
excessive callus, skin breaks, infections and ulcers. Look
for any discoloration. Distal pallor can suggest early
ischaemia, while purple/black discoloration suggests
• Ask the patient to stand so that you can assess the foot
arch; look for deformation of the joints of the feet.
• Feel the temperature of the feet.
• Examine the dorsalis pedis and posterior tibial pulses. If
absent, arrange Doppler studies and evaluate the
ankle:brachial pressure index (p. 69).
• Test for peripheral neuropathy: use a 10-g monofilament
to apply a standard, reproducible stimulus. The technique
Routine review of a patient with diabetes
• Weigh the patient: weight gain in type 2 diabetes is likely
to be associated with worsening insulin resistance while
weight loss in type 1 diabetes often suggests poor
glycaemic control and inadequate insulin dosage.
• For patients on insulin, examine insulin injection sites for
evidence of lipohypertrophy (which may cause
unpredictable insulin release), lipoatrophy (rare) or signs of
• Measure the pulse and blood pressure.
• Test visual acuity and perform fundoscopy (p. 164; see
• Examine the feet (see the next section).
• Perform routine biochemical screening (Box 10.7).
Fig. 10.15 Diabetes and the skin. A Acanthosis nigricans.
B Necrobiosis lipoidica. C Eruptive xanthomata.
10.7 Investigations in diabetes
Investigation Indication/comment
To make a diagnosis of diabetes.
Patients will also monitor capillary blood
glucose to adjust their treatment
HbA1c Can be used for diagnosis of type 2
diabetes and to assess glycaemic burden
Ketones suggest insulin deficiency,
which occurs in type 1 diabetes and in
diabetes due to pancreatic pathology
To confirm a diagnosis of autoimmune
HbA1c An important measure of glycaemic
control over the preceding 3 months;
predicts risk of complications
Urea and electrolytes To assess for the presence of diabetic
Lipid profile To aid estimation of cardiovascular risk
and guide treatment with lipid-lowering
Thyroid function tests To screen for the commonly associated
To assess for early signs of diabetic
nephropathy (microalbuminuria)
To screen for diabetic retinopathy and/or
GAD, glutamic acid decarboxylase.
and the best sites to test are shown in Fig. 10.17. Avoid
areas of untreated callus. Sensory loss typically occurs in
• Assess dorsal column function by testing vibration and
• Undertake a foot risk assessment to guide management
Hair loss and nail dystrophy occur with ischaemia. Feet are
warm in neuropathy and cold in ischaemia. Ischaemic ulcers are
typically found distally: at the tips of toes (see Fig. 10.16B), for
example. There may be skin fissures or tinea infection (‘athlete’s
foot’). Loss of sensation to vibration (p. 143) and proprioception
(p. 144) are early signs of diabetic peripheral neuropathy. Sensory
neuropathy is present if the patient cannot feel the monofilament
on the sites shown in Fig. 10.17. This suggests loss of protective
pain sensation and is a good predictor of future ulceration.
With significant neuropathy, the foot arch may be excessive or
collapsed (rocker-bottom sole). Both conditions cause abnormal
pressures and increase the risk of plantar ulceration (see Fig.
10.16C), particularly in the forefoot. Charcot’s arthropathy is
disorganised foot architecture, acute inflammation, fracture and
bone thinning in a patient with neuropathy. It presents acutely
as a hot, red, swollen foot and is often difficult to distinguish
10.8 Risk assessment of the diabetic foot
Level of risk Definition Action required
High Previous ulceration or amputation, or more than one risk factor
Annual screening should be undertaken by a specialist
Active foot disease Ulceration, spreading infection, critical ischaemia or an
unexplained red, hot, swollen foot
Prompt referral to a multidisciplinary diabetic foot team is
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