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women are often overweight, and have increased risk of type 2 diabetes in middle age or later.
Subjective: Symptoms
Classically: Excessive thirst (polydipsia), excessive urination, especially at night (polyuria/nocturia), weight
loss despite increased appetite and food intake (polyphagia), blurred vision. Patients with new onset diabetes
frequently have no symptoms or may present with complications of diabetes, such as foot ulcers or gangrene.
Focused History: Quantity: How many times do you wake up to urinate each night? (>1 is suspicious).
How much weight have you lost? (weight loss despite increased food intake is suspicious) Is your appetite
increased? Are you unusually thirsty? (polyphagia/polydipsia) Do you notice any blurring of your vision?
Have you had sores on your feet or other wounds that are slow to heal? (typical symptoms) Do your feet
feel as if they are asleep or as if they are not part of your body? (Loss of sensation suggests neuropathy, a
possible complication of diabetes.) Is it difficult or impossible for you to have an erection (males)? (50% male
DM have impotence) Duration: When did your symptoms begin? (more symptomatic, more recent the onset
of symptoms) Other: Does anyone in your family have diabetes? (There is a strong family predisposition
particularly with type 2 diabetes.)
Objective: Signs
Physical examination is usually unreliable for diagnosis of DM.
Using Basic Tools: Vital Signs - BP drop > 20 mm Hg systolic comparing standing vs. supine position
(orthostatic hypotension), tachycardia
Inspection: Central obesity (“beer belly” or “apple on a stick” configuration), dry mucous membranes
(reflecting volume loss/dehydration); ulcers on the soles of the feet; vitiligo (de-pigmented regions of skin can
be associated with type 1 diabetes and other autoimmune endocrine diseases)
Palpation: “Tenting” of the skin (suggests volume depletion); reduced or absent light touch sensation in distal
legs and feet (reflects peripheral neuropathy, associated with diabetes)
Percussion: Absent ankle jerk or knee reflexes (may reflect peripheral neuropathy, associated with diabetes)
Using Advanced Tools: Lab: Test for glucose and ketones on urine dipstick (DM diagnosis).
Assessment:
Differential Diagnosis:
Weight loss/increased appetite - malabsorption states, protein/calorie malnutrition, hyperthyroidism
Polyuria - diabetes insipidus, urinary tract infection, prostatic hypertrophy
Polydipsia - diabetes insipidus
Plan:
Treatment
Primary: Give patients with severe hyperglycemia (> 250 mg/dl) and/or large ketonuria NPH insulin at an
empiric starting dose of 0.25 unit/kg body weight SC twice daily. Give an oral hypoglycemic agent for fasting
blood sugar in the 200-250 mg/dl range: glyburide 5 mg/day or glipizide 5 mg/day are effective and widely
available. Evacuate profoundly symptomatic patients; look for orthostatic hypotension, nausea and vomiting,
“large” ketones on urine dipstick as major indications to evacuate. Give high volume fluid therapy and
intravenous insulin (10 units initially, followed by 5 units per hour) while en route. Give newly diagnosed
diabetics appropriate dietary and exercise regimens (see Patient Education below).
Primitive: Severely symptomatic patients who are volume depleted can be treated with aggressive isotonic
saline infusion intravenously (1-2 liters over one hour, followed by 150-250 cc per hour), pending transport
to a definitive care facility.
Empiric: Empiric drug or insulin therapy is potentially dangerous in the absence of blood glucose testing
and should be avoided.
Patients with positive urine ketones and a rapid respiratory rate probably have profound metabolic acidosis
(ketoacidosis).