Neuropathy

Neuropathy is a common complication of diabetes affecting up to 50% of people who have had diabetes more than 25 years. It classically presents as symmetrical loss of sensation in the feet but may also present with pain or unpleasant alteration of touch sensation (allodynia) in the feet. In addition to peripheral neuropathy, other manifestations include autonomic neuropathy and diabetic mono-neuropathies.

General examination

A thorough general and systems examination is an essential part of the assessment of any patient with a diabetes complication.

Cardiovascular

Assess whether the patient has a postural drop of more than 10 mm Hg in systolic blood pressure between lying and standing. Further signs of cardiovascular autonomic neuropathy may be elicited by performing Ewing and Clarke tests.

Respiratory

Examine for digital clubbing and focal chest signs. They suggest a possible underlying malignancy and paraneoplastic neuropathy as a differential diagnosis of diabetic neuropathy. 

Abdominal

Is the patient cachetic or are there any abdominal masses or hepatomegaly suggesting a possible underlying malignancy and paraneoplastic neuropathy as a differential diagnosis of diabetic neuropathy?

Neurological

Is there a classical 'glove and stocking' distribution sensory loss? Is there wasting of intrinsic muscles of the feet and hand?

Other signs that should be sought include loss of normal foot architecture and clawing of the toes. Classically neuropathic limbs are also hairless and the skin becomes atrophic and shiny.

Asymmetry of signs, or a predominance of proximal signs, should prompt reconsideration of the diagnosis. In some cases of PDN, there will be an absence of sensory signs, but this does not automatically exclude the diagnosis if all others features are consistent with this diagnosis.

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