In approximately 25% of cases, ketoacidotic coma is the first sign of type 1 diabetes mellitus (manifestation coma). During the physical examination of a type 1 diabetic patient (emergency situation), note:
- Symptoms of desiccosis-standing skin folds, rapid weight loss, dry mucous membranes, postural hypotension (drop in blood pressure on standing), hypotension, decreased central venous pressure, lethargy, oliguria (urine output <500 ml)/24 h/anuria (urine output <100 ml/24 h).
- Symptoms of ketoacidosis – Kussmaul’s respiration (very deep and slowed, regular, rhythmic breathing), acetone- or fruit-like fetor, decreased reflexes, paresthesias (sensory deprivation), precoma, coma
- Pseudoperitonitis diabetica – abdominal pressure and possibly release pain.
Physical examination may reveal exsiccosis (dehydration) with standing skin folds in the type 1 diabetic patient who presents acutely/subacutely. The patient is often emaciated and lethargic. Due to ketoacidosis, the patient breathes in rapid but shallow breaths to exhale increased CO2 to counteract acidosis (hyperacidity). An acetone or fruit-like odor (fetor) may be detected in the breath. Blood pH is < 7.2 and standard bicarbonate < 15 mmol/l.
Acidosis may irritate the peritoneum (diaphragm) (pseudoperitonitis diabetica) which manifests as severe abdominal pain in affected patients and may well be mistaken for acute abdomen.
A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body weight, height; furthermore:
- Inspection (viewing).
- Skin, mucous membranes and sclerae (white part of the eye) [Delayed wound healing, pruritus (itching), recurrent therapy-resistant infections for example dermatomycosis; Poorly healing wounds, bacterial or mycotic skin infections (furunculosis (repeated occurrence of numerous boils in different parts of the body), candidamycosis (fungal infection)); balanitis (acorn inflammation; periodontal disease (periodontitis; inflammation of the periodontium)]
- Abdomen (abdomen)
- Shape of the abdomen?
- Skin color? Skin texture?
- Efflorescences (skin changes)?
- Pulsations? Bowel movements?
- Visible vessels?
- Scars? Hernias (fractures)?
- Auscultation (listening) of the heart [due tosecondary diseases such as: coronary heart disease (CHD)].
- Auscultation of the lungs
- Examination of the abdomen
- Auscultation of the abdomen [vascular or stenotic sounds?]
- Percussion (tapping) of the abdomen.
- [Attenuation of tapping sound due to enlarged liver or spleen, tumor, urinary retention?
- Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size]
- Palpation of abdomen, etc. (tenderness?, palpation?, coughing pain?, guarding?, hernial orifices?, renal bearing palpation?)
- Palpation of the pulses [due tosecondary disease: peripheral arterial occlusive disease (pAVK)]
- Inspection (viewing).
- Ophthalmological examination – if necessary due tovisual disturbances [retinopathy].
- ENT medical examination – due topossible secondary disease: sensorineural hearing loss.
- Neurological examination – due toe.g. paresthesias in the area of the feet and lower legs [neuropathy].
- Health check
Square brackets [ ] indicate possible pathological (pathological) physical findings.