Latent auto immune diabetes of adulthood (LADA)

LADA has an auto-immune aetiology like T1DM but tends to present later in life than classical T1DM and often runs a more indolent course, with a slow insidious onset. Indeed some authorities only recognise LADA as a variant of T1DM. Historically, also known as 'type one and a half diabetes'.

General examination

A thorough general examination is an essential part of the assessment in all newly presenting case of diabetes.

Specifically, in the acutely unwell case with DKA, assess whether the patient is dehydrated

Blood pressure

In the newly diagnosed patient, assess whether they are dehydrated, hypotensive or have a postural drop in blood pressure on standing.

At routine follow up, assess for hypertension as this is a potent nephropathy, retinopathy and cardiovascualr disease risk factor.

Foetor

Assess whether the patient has a ketotic foetor.

Neurological examination

In the acutely unwell with DKA, assess whether the patient is obtunded or confused, these are markers of disease severity and should prompt consideration of nursing in a level 3 environment (HDU or ITU).

In the newly diagnosed patient with suspected T1DM, look for hearing aids or a hearing deficit, these can be pointers to the differential diagnsosis of mitochondrial diabetes.

Signs of peripheral neuropathy should also be sought. Although these are very unusual in newly presenting LADA and T1DM, they are present in over 10% of newly diagnosed T2DM.

Abdominal examination

If the patient is presenting in DKA, acute abdominal pain is common and the abdomen should be thoroughly examined to differentiate between a true intra abdominal pathology and abdominal pain associated with metabolic disturbance.

In the newly presenting patient with suspected LADA, hepatomegaly and abdominal aortic aneurysm should be sought as fatty liver and established arterial disease may point to the important differential of T2DM.

Retinal examination

Retinal examination should be a routine part of the examination of all patients with newly presenting diabetes. This is both to establish the baseline and to detect any pre-exisitng retinopathy. Ideally this is performed by digital retinal photographic screening as part of an accredited retinal screening service. At the very least it should be performed using an ophthalmoscope with the pupils fully dilated with a mydriatic agent such as tropicamide 1%.

The presence of established retinopathy at presentation should prompt consideration of the important differential diagnosis of T2DM.

Pedal examination

The feet of all patients presenting with newly diagnosed diabetes should be carefully assessed for vascular and neurological deficit. The dorsalis pedis and posterior tibial pulses should be palpated.

Sensation should be assessed by testing two modalities - usually 10 g monofilament sensation and vibration perception on each foot. While the latter is traditionally undertaken with a 128 Hz tuning fork, a neurothesiometer is preferable as it allows objective quantification of any deficit.

In addition, the general condition of the feet, especially whether or not there are any architectural changes should be recorded.

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