Comprehensive Physical Examination Documentation for Hyperglycemia
A comprehensive physical examination for hyperglycemia should include vital signs with blood pressure measurements, assessment for signs of dehydration, cardiovascular evaluation, neurological status, skin examination, and foot examination to identify complications and guide treatment decisions.
Vital Signs and General Assessment
- Blood pressure measurements: Both seated and standing to detect orthostatic hypotension (a decline >20 mm Hg in SBP or >10 mm Hg in DBP after 1 minute is abnormal) 1
- Height, weight, and BMI calculation: To assess for obesity as a risk factor 1
- Temperature: To screen for infection which can precipitate hyperglycemia 1
- Respiratory rate and pattern: To assess for Kussmaul respirations (deep, rapid breathing) which may indicate diabetic ketoacidosis
Hydration Status Assessment
- Skin turgor: Assess for tenting which indicates dehydration
- Mucous membranes: Check for dryness
- Eyes: Look for sunken appearance
- Mental status: Evaluate for altered consciousness, confusion, or lethargy which may indicate severe hyperglycemia or hyperosmolar state 1, 2
Cardiovascular Examination
- Heart rate and rhythm: Tachycardia may indicate dehydration or infection
- Heart sounds: Assess for murmurs or other abnormalities
- Peripheral pulses: Check strength and symmetry of pulses in all extremities
- Capillary refill time: Should be less than 2 seconds
Neurological Assessment
- Level of consciousness: Document using Glasgow Coma Scale or AVPU (Alert, Voice, Pain, Unresponsive) scale
- Cranial nerve examination: Particularly important in patients with altered mental status
- Motor strength and sensation: Assess for peripheral neuropathy using 10-g monofilament test, vibration or pinprick sensation 1
- Deep tendon reflexes: May be diminished in diabetic neuropathy
Skin Examination
- Acanthosis nigricans: Dark, velvety skin in neck folds and axillae suggesting insulin resistance 1
- Insulin injection sites: Check for lipodystrophy or lipoatrophy 3
- Skin integrity: Look for poor wound healing, infections, or ulcers
- Xanthomas: Yellow cholesterol deposits indicating dyslipidemia
Foot Examination
- Visual inspection: Check for calluses, deformities, ulcers, and nail abnormalities 1
- Pedal pulses: Assess dorsalis pedis and posterior tibial pulses (refer for ankle-brachial index if diminished) 1
- Temperature assessment: Compare bilateral temperature of feet
- Sensory testing: Using 10-g monofilament, vibration testing, or pinprick sensation 1
Abdominal Examination
- Liver size: Hepatomegaly may indicate fatty liver disease
- Tenderness: Assess for abdominal pain which may indicate complications like pancreatitis
Eye Examination
- Fundoscopic examination: To detect diabetic retinopathy (refer to eye specialist) 1
- Visual acuity: Document baseline vision
Additional Focused Assessments
- Thyroid palpation: To screen for thyroid disorders that can affect glucose metabolism 1
- Oral examination: Check for periodontal disease
- Signs of secondary causes: Look for physical features suggesting secondary hyperglycemia (e.g., Cushing's syndrome features like central obesity, facial rounding, easy bruisability) 1
Documentation of Complications
- Macrovascular complications: Document signs of coronary artery disease, peripheral arterial disease, or cerebrovascular disease
- Microvascular complications: Document evidence of retinopathy, nephropathy, or neuropathy
- Signs of acute complications: Document findings consistent with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) 1, 2
This comprehensive physical examination provides critical information for diagnosing hyperglycemia, identifying its etiology, assessing for complications, and guiding appropriate management strategies to reduce morbidity and mortality.