diabetes

1. Diabetes; A clinical approach
PACES Station 5
Mamdouh L Dorrah
MRCP-UK London

2. Introduction
This work is only designed to cover how a case of diabetes could
present in PACES station 5 examination.

3. History taking in patients with diabetes
For the purpose of efficient history taking in patients with diabetes it is
essential to cover the followings;
• Chronology; age of onset – duration – type of DM.
• Control; most recent blood glucose level reading – most recent
HBA1C% reading.
• Medications; insulin or OHGAs – doses and possible side-effects.
• Lifestyle; diet and exercise.
• Complications; visual – vascular – renal – neurological – footcare –
hypoglycemic episodes.

4. Diabetic Neuropathy; Clinical Approach
History
Examination
Investigations

5. Diabetic Neuropathy; Clinical Approach -
History
Full diabetic history
Full neuropathy history
• Sensory symptoms; -ve or
+ve symptoms
• Motor symptoms; weakness.
• Autonomic symptoms;
nausea – vomiting – altered
bowel habit – erectile
dysfunction.
• Gait
Ask about other common
possible causes of chronic
neuropathy
• Vitamin B12 deficiency.
• Folate deficiency.
• Uremia.
• Hypothyroidism.
• Vasculitis.
• Paraneoplastic syndrome.

6. Diabetic Neuropathy; Clinical Approach –
Examination
Overall inspection
Skin
• Trophic changes.
• Ulcers
• Callus
• Hair distribution in
lower limbs
Vascular input Pulses and Capillary Refill.
Neurological examination
• Sensory examination for all
modalities of sensation.
• Motor examination.
• Gait
• Romberg’s test
Tell the examiner that you would like
to complete your examination by
performing complete neurological
examination and dipsticking urine for
glycosuria and proteinuria.

7. Diabetic Neuropathy; Clinical Approach –
Investigations
Neuropathy work-up includes;
• FBC.
• ESR.
• CRP.
• U&E.
• TFT.
• Autoimmune screen.
• Bence-jones protein.
• Syphilis serology.

8. Diabetic neuropathic ulcer; Clinical approach
History
Examination
Investigations

9. Diabetic neuropathic ulcer; Clinical approach
– History
Full diabetic history
Full neuropathy history
Ulcer history
Location – Size – Edges – Color –
Odor – Surrounding skin – Pain.
Vascular history
Intermittent claudication –
Angiogram or Angioplasty
History of recent trauma
Footcare and orthopedist
Follow up

10. Diabetic neuropathic ulcer; Clinical approach
– Examination
Overall inspection
Skin
• Trophic changes.
• Ulcers
• Callus
• Hair distribution in lower
limbs
Ulcer examination
Location – Size – Edges – Color –
Odor – Surrounding skin – Pain.
Vascular input
Pulses and Capillary Refill.
Tell the examiner that you would like
to complete your examination by
performing complete neurological
examination and dipsticking urine for
glycosuria and proteinuria.

11. Diabetic neuropathic ulcer; Clinical approach
Investigations
• Neuropathy work-up.
• Vascular input; Ankle brachial pressure index and Bedside Doppler
angiography.