Pre-Diabetes 1
Doctor Information
Name John Charles 57
Past history:
Nill of note
Medications:
Nill
Last consultation:
Seen by Practice Nurse: came in for over 40’s health check.
Non smoker, Alcohol intake 9 u/week.
Bloods pressure 139/75, pulse 70
BMI 31
Urine dip: NAD
Bloods result:
FBC - normal
U+E - normal
LFT’s - Normal
Cholesterol 4.2
Hba1c 47 mmol/l - abnormal, book appointment with doctor.
Past history:
Nill of note
Medications:
Nill
Last consultation:
Seen by Practice Nurse: came in for over 40’s health check.
Non smoker, Alcohol intake 9 u/week.
Bloods pressure 139/75, pulse 70
BMI 31
Urine dip: NAD
Bloods result:
FBC - normal
U+E - normal
LFT’s - Normal
Cholesterol 4.2
Hba1c 47 mmol/l - abnormal, book appointment with doctor.
Patient Information
John Charles 57
Opening line:
Ive been asked to come see you doc, I rang up to ask about my results, and they told me my sugars were abnormal and I needed to see you.
If asked:
You took up the offer of a health check as you felt that you are getting older, and you wanted to make sure everything was tick tock! Your wife is younger than you by 10 years, and you wanted to make sure you will be around for long enough to support her and your children.
You have done some reading about blood sugars, and you are now worried you have diabetes, you would like to know if this is the case or not.
You have had no symptoms, no thirst, no urinary frequency, no change in weight, no abdominal symptoms, no cardiovascular symptoms. You take no routine medication, and nothing OTC. You have had no medical problems in the past.
There is a family history of heart problems, You remember your dad passed away in his 60s from a heart attack, and your mother had diabetes when she was older.
You hardly drink - maybe 3-4 pints per week on a Saturday evening. You’ve never smoked. Your diet is good, but you admit to being partial to some chocolate and cakes, and this is what has lead to your slight weight gain over the past few years.
You work as a freelance salesman, selling advertising space. This means a lot of driving around to see clients, and by the end of the day you are very tired and don’t feel up to exercising.
Ideas: You have diabetes
Concerns: What does this mean for your driving, you've googled diabetes, and something mentioned about stopping driving, so you got worried and didn't read anymore. Your livelihood involves driving, this concerned you greatly.
Expectations: You want the doctor to help you manage the diabetes, and also write a letter of support saying you can still drive.
Opening line:
Ive been asked to come see you doc, I rang up to ask about my results, and they told me my sugars were abnormal and I needed to see you.
If asked:
You took up the offer of a health check as you felt that you are getting older, and you wanted to make sure everything was tick tock! Your wife is younger than you by 10 years, and you wanted to make sure you will be around for long enough to support her and your children.
You have done some reading about blood sugars, and you are now worried you have diabetes, you would like to know if this is the case or not.
You have had no symptoms, no thirst, no urinary frequency, no change in weight, no abdominal symptoms, no cardiovascular symptoms. You take no routine medication, and nothing OTC. You have had no medical problems in the past.
There is a family history of heart problems, You remember your dad passed away in his 60s from a heart attack, and your mother had diabetes when she was older.
You hardly drink - maybe 3-4 pints per week on a Saturday evening. You’ve never smoked. Your diet is good, but you admit to being partial to some chocolate and cakes, and this is what has lead to your slight weight gain over the past few years.
You work as a freelance salesman, selling advertising space. This means a lot of driving around to see clients, and by the end of the day you are very tired and don’t feel up to exercising.
Ideas: You have diabetes
Concerns: What does this mean for your driving, you've googled diabetes, and something mentioned about stopping driving, so you got worried and didn't read anymore. Your livelihood involves driving, this concerned you greatly.
Expectations: You want the doctor to help you manage the diabetes, and also write a letter of support saying you can still drive.
Examination Findings
No further examination required at this station.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Enquires about sx of diabetes, and risk factors - lifestyle, fhx, shx. Correctly interprets abnormal blood sugar levels. |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice - see below for current guidelines. Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Manages risk effectively, safety netting appropriately Encourages the patient to participate in appropriate health promotion and disease prevention strategies |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient |
Management
Explanation:
All of us have some sugar in our blood, this is necessary for us to live and function. If the level of sugars in our blood is very high, we call that diabetes - you may have heard of this term. There is however a level that is in the grey area between normal and diabetes. If you’re sugar level falls within this grey area, we call this pre-diabetes. If left untreated, there is a chance that this may progress into diabetes. One way to think of this is in-fact as a golden opportunity, if we can alter your lifestyle at this point, there is a chance that we can prevent this from turning into diabetes. The main way in which we prevent this, is by altering your diet, increasing your exercise, and consequently losing weight.
Understanding Blood Sugar Results
Sugars can be measured in many ways: fasting blood glucose (FBG), random blood glucose (RBG), and glycated haemoglobin. You are considered diabetic, if your fasting glucose is 7 or above, your random sugar 11.1 or above, or your ba1c is 48 or above. As the glycated haemoglobin (hba1c) is an average measure over 3 months, and that it does not require a fasting sample, most practices are now switching over to using this test for screening purposes.
It is however important to note that Hba1c is inaccurate (and therefore should not be used), if you are anaemic, have a haemoglobinopathy, are pregnant, symptoms <2m duration, or if you are suspecting type 1 diabetes.
Impaired glucose regulation (IGR) is a term that refers to blood glucose levels that are above the normal range but are not high enough for the diagnosis of Type 2 diabetes, it is referred to by NICE as pre-diabetes. IGR is used to describe the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). IGT and IGF can exist as mutually exclusive conditions, or can occur in combination.
All of us have some sugar in our blood, this is necessary for us to live and function. If the level of sugars in our blood is very high, we call that diabetes - you may have heard of this term. There is however a level that is in the grey area between normal and diabetes. If you’re sugar level falls within this grey area, we call this pre-diabetes. If left untreated, there is a chance that this may progress into diabetes. One way to think of this is in-fact as a golden opportunity, if we can alter your lifestyle at this point, there is a chance that we can prevent this from turning into diabetes. The main way in which we prevent this, is by altering your diet, increasing your exercise, and consequently losing weight.
Understanding Blood Sugar Results
Sugars can be measured in many ways: fasting blood glucose (FBG), random blood glucose (RBG), and glycated haemoglobin. You are considered diabetic, if your fasting glucose is 7 or above, your random sugar 11.1 or above, or your ba1c is 48 or above. As the glycated haemoglobin (hba1c) is an average measure over 3 months, and that it does not require a fasting sample, most practices are now switching over to using this test for screening purposes.
It is however important to note that Hba1c is inaccurate (and therefore should not be used), if you are anaemic, have a haemoglobinopathy, are pregnant, symptoms <2m duration, or if you are suspecting type 1 diabetes.
Impaired glucose regulation (IGR) is a term that refers to blood glucose levels that are above the normal range but are not high enough for the diagnosis of Type 2 diabetes, it is referred to by NICE as pre-diabetes. IGR is used to describe the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). IGT and IGF can exist as mutually exclusive conditions, or can occur in combination.
Blood Sugar Values
Diabetes: (Diabetes UK criteria)
Hba1c: >48 mmol/l or 6.5%
FBG: equal to or > 7.0
RBG: equal to or > 11.1
Impaired Glucose Regulation: (Diabetes uk / NICE criteria)
Hba1c: 42 mmol/l (6.0%) - 47mmol/l (6.4%)
or values below for IGF / IGT
IGF: FBS of between 6.1 and 6.9 (Diabetes UK guidance)
FBS of between 5.5 and 6.9 (NICE Guidance)
IGT: 2 hour OGTT / RBG >7.8 <11.1 with a FBS of <6.1
Currently Diabetes UK recommend using Hba1c alone for diagnosis of diabetes and IGR.
Management:
The management of pre-diabetes varies considerably, depending on who you speak to, or what guidelines you read.
Diabetes uk suggest the following:
NICE however suggest:
It is now known that weight loss, especially through the use of fasting diets, can improve prognosis, and even reverse raised blood sugars / diabetes.
As for driving rules, there are no restrictions in place for pre diabetes. These patients also do not need to be referred for annual eye tests, foot checks, DESMOND etc....
The management of pre-diabetes varies considerably, depending on who you speak to, or what guidelines you read.
Diabetes uk suggest the following:
- Provide intensive lifestyle advice
- Warn patients to report symptoms of diabetes
- Monitor HbA1c annually
NICE however suggest:
- Intensive lifestyle measures with BMI goals of 25 (23 if south asian)
- encouraging physical activity
- dietary changes
- reassess weight and blood sugars annually
- offering metformin / orlistat to aid lifestyle changes if:
- No improvement in sugars despite their participation in an intensive lifestyle-change programme, or
- they are unable to participate in an intensive lifestyle-change programme.
It is now known that weight loss, especially through the use of fasting diets, can improve prognosis, and even reverse raised blood sugars / diabetes.
As for driving rules, there are no restrictions in place for pre diabetes. These patients also do not need to be referred for annual eye tests, foot checks, DESMOND etc....