Health History & Diabetes-Specific Physical Assessment

The Diabetes-Relevant History

A diabetes-focused history starts with the story of the diagnosis itself: age at diagnosis, diabetes type (or type still being clarified), and duration of disease, since duration is one of the strongest predictors of complication risk. Ask about the full treatment trajectory — prior and current medications, insulin regimens, and device use (pump, continuous glucose monitor) — and how well the person tolerates and adheres to each. Glycemic history matters as much as the current number: recent A1C trend, CGM-derived Time-in-Range or Glucose Management Indicator (GMI) if available, and a detailed hypoglycemia history (frequency, severity, timing, and whether symptoms are still felt or have become unaware). Document any DKA or HHS hospitalizations, since either signals a gap in either physiology or self-management that the plan must address. Ask specifically about prior participation in Diabetes Self-Management Education and Support (DSMES) and what was and was not retained, and screen for already-known complications (retinopathy, nephropathy, neuropathy, cardiovascular disease) so the exam and education plan target this person's real risk rather than population averages.

The General Health History

Layered onto the diabetes-specific story is the general history every CDCES documents at intake and updates at follow-up:

• Family history — diabetes (type, and which relatives), autoimmune disease, premature cardiovascular disease
• Medical history — hypertension, dyslipidemia, obesity, obstructive sleep apnea, PCOS, thyroid disease, and other comorbidities that interact with glycemic control
• Mental health history — depression, anxiety, disordered eating, and any prior diabetes distress
• Substance use — alcohol, tobacco, and other substances, all of which alter glycemic patterns, hypoglycemia risk, and long-term complication risk
• Surgical history — including metabolic/bariatric surgery, which changes nutrient absorption, medication dosing, and hypoglycemia risk
• Allergy history — medication allergies plus adhesive or latex sensitivities relevant to CGM sensors, pump infusion sets, and pen needles
• Medication reconciliation — every prescription, over-the-counter product, and complementary/alternative remedy, since many common agents (decongestants, niacin, corticosteroids, some herbal supplements) raise or lower glucose

Diabetes-Specific Physical Assessment

Biometrics

Height, weight, and calculated BMI are baseline at every visit; waist circumference adds information BMI alone misses because it reflects visceral adiposity directly, which drives insulin resistance independent of total body weight.

Injection and Infusion Site Inspection

Everyone using injectable therapy needs their sites inspected and palpated at every visit, not just looked at. Lipohypertrophy — a thickened, rubbery area of subcutaneous tissue caused by repeated injections or infusions into the same small spot — is easy to miss on visual inspection alone but easy to feel on palpation. It matters clinically because insulin injected into lipohypertrophic tissue absorbs erratically and unpredictably, producing unexplained hyperglycemia, hypoglycemia, or swings between the two in the same person. Teach systematic site rotation within one anatomic region (for example, dividing the abdomen into quadrants and rotating through them) rather than jumping between distant regions, because absorption rate itself differs by region. Instruct the person to avoid injecting into any area with detectable lipohypertrophy until it resolves, which can take weeks to months once injections stop in that spot.

Extremity and Foot Exam

The comprehensive diabetes foot exam is completed at least annually — more often for feet already at elevated risk — and combines three components:

1. Visual inspection — skin integrity, ulcers, calluses, deformity (including Charcot changes), and nail/web-space condition
2. Vascular assessment — palpation of the dorsalis pedis and posterior tibial pulses
3. Neurological assessment — 10-gram Semmes-Weinstein monofilament testing for loss of protective sensation, plus vibration perception (128-Hz tuning fork) and ankle reflexes

Absent monofilament sensation at one or more standard testing sites identifies a foot at materially higher ulceration and amputation risk and should trigger referral and intensified foot-care education, including daily self-inspection and appropriate footwear.

Skin Exam

Diabetes-associated skin findings to actively look for include acanthosis nigricans (velvety hyperpigmentation at the neck or axillae signaling insulin resistance), diabetic dermopathy (pigmented pretibial macules), necrobiosis lipoidica diabeticorum, recurrent fungal or bacterial infections, dry or fissured skin, and delayed wound healing. Each finding feeds directly back into the education plan: acanthosis nigricans becomes a teaching opportunity about insulin resistance, while any active fungal infection or slow-healing wound reprioritizes foot care and glycemic-control education for that visit.

Taken together, the history and physical exam are not a one-time intake ritual. Injection sites, feet, skin, and weight all change over the course of a chronic disease, so each is reassessed at follow-up and used to keep the individualized education plan current rather than static.

Documenting and Acting on Findings

Every assessment finding should be recorded in a way the whole care team can act on: a lipohypertrophic area is charted by location so the next visit checks the same spot for resolution, and an absent monofilament response is documented by testing site so risk stratification is reproducible across clinicians. Trend the biometrics rather than reading them in isolation — a rising waist circumference with a stable BMI still signals worsening visceral adiposity and should prompt a lifestyle conversation before the scale moves. A new area of acanthosis nigricans or a foot pulse that is harder to palpate than at the prior visit is more meaningful than either finding read alone. The CDCES uses these physical findings, together with the history, to decide which self-care behaviors and education topics are highest priority for that person at that visit — the assessment drives the plan, not the reverse.