What abnormalities would you expect to find in a head-to-toe (head to toe) exam?

Expected Findings in a Head-to-Toe Examination for Diabetes Patients

In a comprehensive head-to-toe examination of a diabetes patient, you should expect to find abnormalities related to microvascular and macrovascular complications, with particular attention to neurological, vascular, and skin manifestations. 1, 2

Vital Signs and General Appearance

• Orthostatic blood pressure changes may be present due to autonomic neuropathy 1
• General appearance may show evidence of wasting, obesity, or lipodystrophy 2

Head and Neck

• Carotid bruits may be present due to macrovascular disease 2
• Visual inspection may reveal evidence of acanthosis nigricans (dark, velvety skin patches) on the neck, indicating insulin resistance 1

Skin

• Acanthosis nigricans may be present in skin folds 1, 3
• Necrobiosis lipoidica diabeticorum (yellow-brown, atrophic plaques typically on shins) 3
• Diabetic dermopathy (light brown, scaly patches) 3
• Insulin injection sites may show lipodystrophy or lipohypertrophy 1
• Skin may appear dry, with poor turgor due to dehydration 2

Cardiovascular System

• Heart examination may reveal tachycardia or arrhythmias related to autonomic neuropathy 2
• S3 gallop or other signs of heart failure may be present in advanced disease 2

Abdominal Examination

• Hepatomegaly may be present due to non-alcoholic fatty liver disease (NAFLD) 1
• Delayed gastric emptying (gastroparesis) may present as abdominal distention 1

Neurological Examination

• Loss of protective sensation (LOPS) in feet detected by:
  • Abnormal 10-g monofilament testing (inability to feel the monofilament at specific sites) 1
  • Diminished vibration sensation using 128-Hz tuning fork 1, 2
  • Reduced pinprick or temperature sensation 1
  • Absent ankle reflexes 1, 2
• Motor neuropathy may present as muscle wasting, especially in intrinsic foot muscles 2
• Autonomic neuropathy may manifest as dry skin due to reduced sweating 4

Vascular Examination

• Diminished or absent pedal pulses (dorsalis pedis and posterior tibial) 1
• Delayed capillary refill time (>2 seconds) 2
• Rubor on dependency and pallor on elevation in advanced peripheral arterial disease 2
• Ankle-brachial index (ABI) may be abnormal (<0.9 or >1.3) 1

Foot Examination

• Skin integrity issues: calluses, ulcers, fissures, or infections 1
• Foot deformities: bunions, hammertoes, Charcot foot, prominent metatarsal heads 1, 2
• Nail abnormalities: thickened nails, fungal infections 1
• Reduced or absent sweating (anhidrosis) detected by Neuropad test 4
• Areas of increased pressure or friction that may lead to ulceration 1

Musculoskeletal System

• Limited joint mobility (particularly in hands - "prayer sign") 2
• Dupuytren's contracture 2
• Trigger finger 2

Special Considerations

• In areas with neurological deficit, inflammatory skin conditions may present atypically or be absent 5
• Patients with sensory neuropathy may have painless ulcers they are unaware of 1
• Patients with previous foot ulcers or amputations require more careful inspection 1

Remember that findings may vary based on diabetes duration, glycemic control, and presence of comorbidities. The examination should be thorough and systematic, with particular attention to the feet in all diabetes patients 1.