Although DM can occur at any time and in both genders, the incidence increases with age, most commonly occurring in adults after age 30. Type 1 most commonly develops in childhood before age 20 but can occur at any age. Onset is often very abrupt. Because of the early age of onset, teenagers often deal with the long-term complications of the disease. Whites are more typically affected with type 1 DM than are people of color.
Type 2 DM usually occurs after the age of 30, particularly in individuals who are overweight or have hereditary factors. Gestational diabetes mellitus (GDM), which is present during pregnancy, occurs in 3% of pregnant women, usually in those older than 30. Type 2 DM is more common in Native Americans, Hispanics, and African Americans than in whites but the incidence is equal in females and males in all populations. Type 2 DM is becoming increasingly common because DM prevalence increases with age, and people are living longer than in past centuries. In addition, it is also more frequent in younger people in accordance with the rising prevalence of childhood obesity.
284 Diabetes Mellitus
HISTORY. Establish a history of the patient's usual weight gains and losses; weight loss is common in type 1 DM. Determine if the patient has been under stress. Ask females of childbearing age if they are pregnant. Establish a history of using medications that antagonize the effects of insulin.
Ask if the patient has experienced excessive thirst (polydipsia), excessive urination (polyuria), or excessive hunger (polyphagia). The most common symptom of DM is fatigue; determine if the patient has experienced fatigue out of the ordinary. Patients with type 2 DM may not report these symptoms. However, ask whether the patient has experienced any recent itching or blurred vision or frequent infections, which are common complaints with type 2 DM. Question if the patient has experienced any visual difficulties, kidney problems, or changes in circulation and sensation to the extremities such as numbness or tingling (paresthesia) or pruritus.
PHYSICAL EXAMINATION. Appearance may be entirely normal, or the patient with type 1 DM may have weight loss, muscle wasting, and loss of subcutaneous fat. The patient with type 2 DM, by contrast, may have thin limbs with fatty deposits around the face, neck, and abdomen. Observe the color of the skin, and note any changes in sensation of temperature, touch, and pain. Examine both feet closely, including the spaces between the toes, for signs of skin ulcers or infection. Assess the legs and feet to identify any unhealed wounds or ulcers. Check the temperature of the skin, which often feels cool, and the skin turgor, which is often poor.
When assessing vital signs, you may note hypertension, a common complication in diabetic patients. Palpate the peripheral pulses to determine their strength, regularity, and symmetry. During the neurological examination, use an ophthalmoscope to evaluate the patient for retinopathy or cataracts. Assess the patient for any signs and symptoms of hypoglycemia or hyperglycemia (Table 2).
PSYCHOSOCIAL. The need for daily management with medications, diet, and exercise repeatedly reminds the individual of the illness. In addition, the reality of a long-term illness may affect the individual's view of herself or himself, resulting in lower self-esteem. Young people with type 1 DM may have trouble managing developmental tasks and a chronic disease simultaneously. Parents may become overprotective, and children may have delayed emotional maturation.
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