What comprehensive physical examination should be performed at diagnosis and annually for a patient with type 2 diabetes mellitus, focusing on cardiovascular risk, obesity, and early diabetic complications?

Physical Examination for Type 2 Diabetes Mellitus

At diagnosis and annually thereafter, perform a comprehensive physical examination that includes blood pressure measurement, BMI calculation, comprehensive foot examination with monofilament testing, and assessment for acanthosis nigricans, while ensuring dilated eye examination by an ophthalmologist occurs shortly after diagnosis. 1, 2

At Diagnosis: Essential Physical Examination Components

Cardiovascular and Obesity Assessment

• Measure blood pressure at every visit, as hypertension is present in a significant proportion of patients with T2DM and requires optimization to reduce microvascular and macrovascular complications 2, 3
• Calculate BMI to assess obesity status, which is critical for risk stratification and treatment planning, particularly when considering metabolic surgery for those with BMI >35 kg/m² 2
• Inspect for acanthosis nigricans (darkened, velvety skin in body folds), which indicates insulin resistance and is commonly present in T2DM 4

Comprehensive Foot Examination

Perform a detailed foot examination at diagnosis and annually, which must include all of the following components 2:

• Visual inspection for deformities, skin breakdown, calluses, or ulcers 2
• Assessment of dorsalis pedis and posterior tibial pulses 2
• Loss of protective sensation testing using 10-g monofilament on plantar surfaces 2, 1
• Vibration sensation testing with 128-Hz tuning fork on great toe 2
• Pinprick sensation testing 2
• Ankle reflex testing 2

This comprehensive approach identifies distal symmetric polyneuropathy, which should be screened at diagnosis in all type 2 diabetes patients 2, 1. The foot examination is critical because patients with loss of protective sensation and structural abnormalities require referral to foot care specialists for ongoing preventive care 2.

Skin Examination Beyond Feet

• Examine injection sites if the patient is on insulin therapy to identify lipohypertrophy or lipoatrophy 4
• Assess for diabetic dermopathy (shin spots), necrobiosis lipoidica, or other diabetes-related skin changes 4

Annual Physical Examination Requirements

Blood Pressure Monitoring

• Measure blood pressure at every routine visit, not just annually, as this is essential for detecting and managing hypertension 2, 3
• For adults, hypertension is defined as BP ≥130/80 mmHg, requiring lifestyle modification and potentially pharmacologic intervention 2

Repeat Comprehensive Foot Examination

• Perform the complete foot examination annually using the same components described above (inspection, pulses, monofilament, vibration, pinprick, ankle reflexes) 2, 1
• This annual screening identifies progressive neuropathy and peripheral arterial disease early, allowing for timely intervention 2

Weight and BMI Assessment

• Document weight and calculate BMI annually to monitor for weight changes that may indicate need for treatment intensification or adjustment 2
• Weight management is an important component of T2DM treatment, though no specific diet has proven most effective for improving health outcomes 5

Critical Specialist Referrals Based on Physical Findings

Ophthalmology

• Dilated comprehensive eye examination by an ophthalmologist or optometrist should occur shortly after diagnosis, as up to 30% of type 2 diabetes patients have retinopathy at diagnosis and 3% already have clinically significant macular edema requiring immediate intervention 1, 2
• The examination must include visual acuity testing, slit-lamp biomicroscopy, intraocular pressure measurement, gonioscopy, stereoscopic examination of the posterior pole, and peripheral retinal examination via indirect ophthalmoscopy 1
• Repeat annually if retinopathy is present, or every 2 years if glycemic control is adequate and eye exam is normal 2

Podiatry/Foot Care Specialist

• Refer patients with loss of protective sensation, structural foot abnormalities, history of foot ulcers, or peripheral arterial disease to foot care specialists for ongoing preventive care and lifelong surveillance 2

Nephrology

• While not based on physical examination alone, refer if there is worsening urinary albumin-to-creatinine ratio or decrease in estimated GFR 2

Additional Physical Examination Considerations

Thyroid Examination

• Palpate the thyroid gland at diagnosis, as autoimmune thyroid disease is more common in patients with diabetes, particularly type 1 diabetes 2, 4

Hepatomegaly Assessment

• Palpate for hepatomegaly, as nonalcoholic fatty liver disease is common in T2DM and should be evaluated with liver enzyme testing at diagnosis and annually 2

Sleep Apnea Screening

• Screen for symptoms of obstructive sleep apnea at each visit (snoring, witnessed apneas, daytime somnolence, morning headaches), with referral to sleep specialist if indicated 2

Common Pitfalls to Avoid

• Do not skip the comprehensive foot examination even in younger patients or those without symptoms, as neuropathy screening must begin at diagnosis in type 2 diabetes 2, 1
• Do not rely solely on patient-reported symptoms for neuropathy assessment, as many patients have asymptomatic loss of protective sensation that can only be detected through structured examination 2
• Do not delay ophthalmology referral until symptoms develop, as retinopathy may be present at diagnosis and early intervention prevents vision loss 1
• Do not measure blood pressure only annually—it should be checked at every routine visit to optimize cardiovascular risk reduction 2, 3
• Do not perform routine screening electrocardiograms, echocardiograms, or stress testing in asymptomatic youth or adults with type 2 diabetes, as this is not recommended 2