'Diabetes'
Doctor Information
Jeremy Newsam, age 49
Past Medical History:
Essential Hypertension
Type II Diabetes
Medication History:
Metformin 500mg TDS
Ramipril 2.5mg OD
Sitagliptin 100mg OD
Previous consultations:
Three weeks ago:
Seen by Giles Kennedy (Health Care Assistant): 16:59 pm
Diabetic Review:
Height: 178cm
Weight: 105kg
BMI: 33.2
Pulse: 83 regular
Blood Pressure: 148/89
Bloods taken today.
Blood Test Results:
FBC: Normal
U+E: Normal
LFT's: Normal
Hba1c: 89
Notes: Hba1c on the rise, needs appointment with a GP
Past Medical History:
Essential Hypertension
Type II Diabetes
Medication History:
Metformin 500mg TDS
Ramipril 2.5mg OD
Sitagliptin 100mg OD
Previous consultations:
Three weeks ago:
Seen by Giles Kennedy (Health Care Assistant): 16:59 pm
Diabetic Review:
Height: 178cm
Weight: 105kg
BMI: 33.2
Pulse: 83 regular
Blood Pressure: 148/89
Bloods taken today.
Blood Test Results:
FBC: Normal
U+E: Normal
LFT's: Normal
Hba1c: 89
Notes: Hba1c on the rise, needs appointment with a GP
Patient Information
Jeremy Newsam, age 49
Opening Line: I’ve been told that you wanted to see me, I’m guessing it’s about my blood tests.
History: You already know about your results, as you’ve already asked reception. You’re aware that your blood sugars are getting higher and higher. You feel well in yourself. Your vision is fine. Whilst you are aware that higher blood sugars are not what the doctor wants, you feel well in yourself, and are not thirsty, don't have polyuria, and are not feeling tired. Your diet is poor, but only because your job doesn't lend itself very well to a regular diet. Easy access to drive through's and motorway services don't help your eating habits.
Reveal only if asked:
Your compliance with medication is very poor. You often forget to take your medication, especially the Metformin. Not only is it difficult to take with food 3 times per day. You also don't remember to take your Rampril and sitagliptin that often, as you're out the door early most days, and find it difficult enough to remember to have a breakfast, let alone take your morning pills. You find that you're just so busy, that the tablets are just not a priority for you right now.
Social History: You work as a long distance lorry driver, and have done for 25 years. Eating healthy and regular meals is always difficult due to the varied nature of you work. Your work always starts very early, and you have difficulty remembering to take the tablets before you leave for work.
You don't smoke and you hardly drink any alcohol. You're working a lot of extra shifts at the moment, as your oldest child is struggling. He is in Jail for the second time, at the moment; for stealing. He will be out in 6 months. You know that he is a good person deep down, but that he struggles with finding work. This often leads him being unemployed and he then spends time with the wrong people. You want to try to break this pattern for him, and are saving up to help him start his own business when he is out. You're hope is that this will get him financially stable, and prevent him from going back to Jail. Working less is not an option for you at this moment in time.
Family History: You are the youngest of two brothers. You Both suffer from diabetes. Your Dad did also, although he passed away from a heart attack at the age of 60, and you're hoping the same doesn't happen to you. You have son and a daughter.
Ideas and concerns: You genuinely feel you're doing the best you can, but your work makes taking all these tablets, especially taking tablets in the morning difficult. You know the potential risk with the diabetes, and would prefer to get the sugars down if possible.
Expectations: Your expectations are that the Doctor will likely give you another tablet, as long as this tablet doesn't give you issues with your HGV license (see below)
Reactions: You will happily go along with whatever the doctor advises. However if the doctor wants to give you another tablet, you will be happy to take it as long as it doesn't cause a problem with your driving. You know that some diabetes medications can cause problems, so you don't want anything that will give you "hypo's". You also know that insulin will interfere with your ability to hold a HGV license, so you definitely don't want this.
Opening Line: I’ve been told that you wanted to see me, I’m guessing it’s about my blood tests.
History: You already know about your results, as you’ve already asked reception. You’re aware that your blood sugars are getting higher and higher. You feel well in yourself. Your vision is fine. Whilst you are aware that higher blood sugars are not what the doctor wants, you feel well in yourself, and are not thirsty, don't have polyuria, and are not feeling tired. Your diet is poor, but only because your job doesn't lend itself very well to a regular diet. Easy access to drive through's and motorway services don't help your eating habits.
Reveal only if asked:
Your compliance with medication is very poor. You often forget to take your medication, especially the Metformin. Not only is it difficult to take with food 3 times per day. You also don't remember to take your Rampril and sitagliptin that often, as you're out the door early most days, and find it difficult enough to remember to have a breakfast, let alone take your morning pills. You find that you're just so busy, that the tablets are just not a priority for you right now.
Social History: You work as a long distance lorry driver, and have done for 25 years. Eating healthy and regular meals is always difficult due to the varied nature of you work. Your work always starts very early, and you have difficulty remembering to take the tablets before you leave for work.
You don't smoke and you hardly drink any alcohol. You're working a lot of extra shifts at the moment, as your oldest child is struggling. He is in Jail for the second time, at the moment; for stealing. He will be out in 6 months. You know that he is a good person deep down, but that he struggles with finding work. This often leads him being unemployed and he then spends time with the wrong people. You want to try to break this pattern for him, and are saving up to help him start his own business when he is out. You're hope is that this will get him financially stable, and prevent him from going back to Jail. Working less is not an option for you at this moment in time.
Family History: You are the youngest of two brothers. You Both suffer from diabetes. Your Dad did also, although he passed away from a heart attack at the age of 60, and you're hoping the same doesn't happen to you. You have son and a daughter.
Ideas and concerns: You genuinely feel you're doing the best you can, but your work makes taking all these tablets, especially taking tablets in the morning difficult. You know the potential risk with the diabetes, and would prefer to get the sugars down if possible.
Expectations: Your expectations are that the Doctor will likely give you another tablet, as long as this tablet doesn't give you issues with your HGV license (see below)
Reactions: You will happily go along with whatever the doctor advises. However if the doctor wants to give you another tablet, you will be happy to take it as long as it doesn't cause a problem with your driving. You know that some diabetes medications can cause problems, so you don't want anything that will give you "hypo's". You also know that insulin will interfere with your ability to hold a HGV license, so you definitely don't want this.
Examination Findings
Examination
No examination required in this case.
No examination required in this case.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic approach to data gathering, without making any assumptions Makes own assessment of history Asks about medication compliance Ask about family history Establish other risk factors for cardiovascular disease and Diabetes. Asks about stress, and other factors interfering with good compliance |
NEGATIVE INDICATORS
Makes assumptions about the patient Fails to get salient details from history, previous examinations and investigations Data gathering is unsystematic Fails to identify poor compliance Fails to identify ongoing stress |
Clinical Management Skills
|
POSITIVE INDICATORS
Identifies that compliance is main issue Manages compliance issues Helps provide options to help with stress Adequate safety netting Correctly identifies that further medication unlikely to be the best option in this case Correctly identifies many reversible risk factors and suggests intensive lifestyle intervention in this case. (weight / poor diet etc..) |
NEGATIVE INDICATORS
Doubtful about diagnosis Explanation lacking detail, or providing incorrect information Unable to explain probable causality or role of current lifestyle in pre-diabetes Unclear about timeframe for follow up Safety netting absent or incomplete Agrees to start unlicensed medication or prescribes outside of guidance Doesn’t recommend Intensive lifestyle intervention for management in this case. |
Inter Personal Skills
|
POSITIVE INDICATORS
Identifies the patient’s health beliefs, their agenda, and their ICE Establishes concern for diabetic complications. Uses explanations that are relevant and understandable to the patient, and lacking in jargon Shows sensitivity and empathy for the patient’s feelings Works with the patient to develop a shared management plan |
NEGATIVE INDICATORS
Fails to identify the patient’s heath beliefs, agenda or ICE Doesn’t establish concern for diabetic complications. Explanation absent or filled with jargon Fails to empathise with the patient’s situation Uses a doctor centred approach |
Management
This case requires you to know and be confident about Pre-diabetes, in order to challenge the patient’s expectations regarding treatment.
Let’s start with a patient explanation:
Everyone has sugar in their blood, it’s normal and an important source of energy. If the blood sugars are very high, we would call this diabetes. Pre diabetes is when your blood sugars are higher than normal, but not quite high enough to be called diabetes. We know that 5-10% of people with pre-diabetes go onto develop diabetes each year, and that we need to act now if we wish to reduce this risk.
Let’s start with a patient explanation:
Everyone has sugar in their blood, it’s normal and an important source of energy. If the blood sugars are very high, we would call this diabetes. Pre diabetes is when your blood sugars are higher than normal, but not quite high enough to be called diabetes. We know that 5-10% of people with pre-diabetes go onto develop diabetes each year, and that we need to act now if we wish to reduce this risk.
Diagnosis:
Pre-diabetes is not a condition recognised by WHO, however NICE suggests a HbA1c between 42-47 mmol/mol (6.0-6.4%) or a Fasting Plasma Glucose of 5.5-6.9 be considered as ‘high risk’ of developing diabetes, and is generally considered the range consistent with diagnosis of pre-diabetes, but please be aware that lab ranges can vary locally.
Unlike diabetes, there is no recommendation re how many tests should be done before diagnosing the condition, however common sense would dictate more than one, in case of let errors etc..
To read more about diagnosing diabetes and pre-diabetes - read our initial case here
Management:
NICE has a flow chart that has been reproduced below, and can be accessed here in the full guidance. (https://www.nice.org.uk/guidance/ph38/chapter/1-Recommendations#recommendation-19-metformin)
NICE has a flow chart that has been reproduced below, and can be accessed here in the full guidance. (https://www.nice.org.uk/guidance/ph38/chapter/1-Recommendations#recommendation-19-metformin)
click the image for the high resolution original
The bit we are interested in is the management of the high risk group. NICE suggests that the mainstay of management should be intensive lifestyle-change programme, please see below for more details:
Intensive Lifestyle Change Programme
The Use of Medication
NICE suggests that medication should only be started if:
The only other medication for pre-diabetes that is recommended by NICE is Orlistat, if the BMI is >28 and they are:
Intensive Lifestyle Change Programme
- Reducing weight so that BMI is below 25 (or 23 if of South Asian, or Chinese descent)
- Aim to reduce 5-10% of body weight by reducing caloric intake
- Increase dietary fibre intake
- Choose foods that are lower in saturated fats
- Choose skimmed or semi-skimmed products
- Choose fish and lean meats instead of processed meats
- Avoid frying or roasting food
- Avoid high sugar foods (cakes, chocolates, biscuits etc..)
- If BMI above 30 (27.5 is of South Asian or Chinese descent) offer a structured weight loss programme.
- Another options is the 5:2 diet, which some patients can find easier to adhere to, and can yield good results. If you’re unfamiliar with the 5:2 diet, a patient information leaflet can be accessed here: (http://patient.info/health/52-diet)
- Increasing exercise levels to 150minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity activity. if this is unachievable, emphasise that even a small increase in exercise levels can be beneficial.
The Use of Medication
NICE suggests that medication should only be started if:
- Patients are unable to undertake the above programme, or if,
- Despite participation, blood sugar readings show that they are still progressing towards diabetes.
The only other medication for pre-diabetes that is recommended by NICE is Orlistat, if the BMI is >28 and they are:
- Unable to undertake intensive lifestyle change (due to a disability or a medical reason)
- Not benefitting from the intensive lifestyle-change programme