Skin

Skin abnormalities are common with diabetes . With prolonged hyperglycemia, the skin can appear dry and flaky. If the skin is itchy, the patient may have scratch marks. The skin may be flushed and warm in patients with DKA or pale and cool in those with HHNK syndrome, depending on the blood glucose level. A patient with hyperglycemia may have no diaphoresis when she has a fever because of the dehydration caused by polyuria.

When a patient’s diabetes goes undetected or is poorly controlled, glucose accumulates under the skin and causes skin infections. Candidiasis, a common infection, may cause redness, maceration, and oozing. The patient also may have small pustular lesions. Infections usually occur in areas that have a lot of moisture, such as under the arms, under the breasts, and in the groin.

Your patient’s legs and feet may show signs of peripheral vascular disease caused by prolonged hyperglycemia. The skin may appear shiny and thin and be cool to the touch. You may also see evidence of hair loss. Toenails may appear thick and ridged. And the patient may have leg or foot ulcers. You may note brown spots on your patient’s shins-a sign of small internal hemorrhages resulting from minor trauma to the area. The hemorrhages are harmless in themselves, but they do indicate that changes have occurred to peripheral blood vessels as a result of diabetes.

Long-standing hyperglycemia may lead to diabetic neuropathy, which can be further classified as peripheral or autonomic. Carefully examine your patient’s arms and legs for peripheral neuropathy. You may find signs of atrophy of the small muscles, which will be most pronounced in the interosseous space between the thumb and first finger. Trauma to the hands caused by cigarette or stove burns may indicate sensory loss.

Peripheral neuropathy that affects the feet and legs is usually bilateral and symmetric, so compare physical findings in both legs. Peripheral neuropathy may also cause deep tendon reflexes to be diminished or absent, and the patient may have leg or foot ulcers. Sensory testing involving pain, temperature, light touch, vibration, position, and discriminative sensations may reveal that sensations are decreased or absent.

Autonomic neuropathy develops when the nerves that lead to various organs are damaged by hyperglycemia. Most abnormalities of autonomic neuropathy can be detected during the health history and through diagnostic tests. Some patients with autonomic neuropathy may experience unpredictable diarrhea (especially at night) or difficulty urinating.

Complications of Diabetes

A physical examination of a patient who has already been diagnosed with diabetes will help you identify the effects of acute and chronic complications. You may also discover body changes that have occurred as a result of therapy, especially insulin injections and blood glucose level monitoring.

Hypoglycemia sometimes causes no signs or symptoms and must be detected by blood glucose monitoring. If hypoglycemia goes undetected, the sudden collapse of a patient may be the first warning sign. Here’s what happens: Because the nerves of the autonomic nervous system are coated with glucose for a long time, nerve transmission slows. And because of this slowing, the patient doesn’t experience the early signs and symptoms of hypoglycemia. Instead, she experiences unexpected hypoglycemic episodes, such as a collapse.

Because diabetes is commonly treated by tightly controlling blood glucose levels, you should examine your patient for and ask her about signs and symptoms of hypoglycemia. One of the major adverse effects of tight control is an increase in the number and severity of hypoglycemic episodes. If your patient has diabetic retinopathy, tight control may briefly worsen the condition, so immediately report any changes in your patient’s visual acuity.

Be sure to examine the sites where your patient has injected insulin and drawn blood for self-monitoring. If she uses pork or beef insulin, you may note skin abnormalities, such as fatty accumulations under the skin or areas of atrophy, which appear as hollow spots. Repeated injections into the same spot cause these abnormalities and can adversely affect insulin absorption. To find out if your patient is actually performing blood glucose monitoring, examine her fingertips for puncture marks and calluses. A callus may be an ideal area from which to draw blood because the patient will experience less discomfort and be more likely to test her blood regularly.