Type 2 diabetes mellitus

Type 2 diabetes accounts for approximately 90% of all cases of diabetes. Insulin resistance is the cardinal pathogenic factor and patients are therefore initially hyper insulinaemic although eventually beta cell failure intervenes. Diagnosis is often made on clinical grounds but can be confirmed by measuring C-peptide and/or insulin levels. Management is by a combination of lifestyle changes, oral hypoglycamics and eventually insulin therapy becomes unavoidable in the overwhelming majority of cases.

General examination

The patient should be generally assessed to ascertain whether they are sufficiently unwell to merit admission to hospital but this is rarely necessary in cases of newly diagnosed T2DM.

In addition, signs of coexistent pathologies such as ischaemic heart disease, peripheral vascular disease and non alcoholic fatty liver disease should be sought.

Blood pressure

Assess whether the patient is hypertensive. 

Hypertension is an important risk factor for many complications of T2DM including ischaemic heart disease, cerebrovascular disease, nephropathy and retinopathy. 

Abdo

The presence of hepatomegaly is likely to indicate coexistent non alcoholic fatty liver disease but should prompt further investigation with a liver USS and set of LFT blood tests at the least.

Feet

Approximately 10% of newly diagnosed cases of T2DM will already have established microvascular complications.

Feet should therefore be examined for evidence of neuropathy as well as ulceration and vascular insufficiency.

Retinal screening

Approximately 10% of newly diagnosed cases of T2DM will already have established microvascular complications.

Some form of retinal screening should therefore be undertaken, ideally by digital retinal photography as part of an accredited retinal screening programme, but at the very least dilated fundoscopy should be performed by the examining physician.

Cardiovascular system

Signs of congestive cardiac failure should be sought in order to detect established cardiac disease but also as a base line in case thiazoledinedione therapy be considered.

Diabetesbible is for health professionals