csa_course_case_diabetic_strips.pdf
TRANSCRIPT
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CSA course case CANDIDATES BRIEF
Patient medical records Name: Patricia Amiobie (38 year old) Past medical history: Diabetes Drug history: metformin 500mg bd
Consultation (2 weeks ago) Newly diagnosed type 2 diabetic started on metformin 500mg bd. Asymptomatic denies any symptoms. Will trial diet change but initiated on metformin.
Blood tests (3 weeks ago) Glu (fasting) 8.2 HbA1c 6.8
Consultation (3 weeks ago) Noted raised sugar levels. To repeat and review in 2 weeks time to confirm diagnosis
Blood tests (4 weeks ago) Na 141 K 4.0 Cr 60 Ur 3.2 eGfr >90 Chol 3.7 Glu (fasting) 9.2
Consultation (6 weeks ago) Patient a frequent attendee to practice. Would like routine blood test. Offered to the patient. Denies any symptoms. Review post blood tests
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CSA course case Request for test strips ACTORS BRIEF You are Patricia Ameobi, a 38 year old typist
Approach: You attend well dressed and attend frequently almost fortnightly with little niggles about her health
Opening statement: Doctor I am a bit worried about my diabetics. Can I be prescribed a self monitoring kit please?
History Open history:
You are a newly diagnosed type 2 diabetic (well control)
You read recently in a womans magazine that checking the blood glucose at home helps control the sugar tighter and prevent any symptoms and in fact can help reduce future complications as well
You do not remember if the article was speaking about type 1 or type 2 diabetes; nor how badly controlled ones diabetes is before needing it
You are desperate to control your diabetes and do anything to get good control
You attend today keen to be prescribed a blood glucose kit on the NHS along with sufficient strips to check your sugar levels regularly
CUE: You are a typist, you enjoy your work and your vision is important to you. You have regular eye checks (i.e. want BM glucometer to prevent eye damage)
Reveal history if asked:
Ideas You think that the only way to control your sugar levels is to monitoring it closely with a home kit. You think that by monitoring your sugar levels you can adjust your dose of metformin daily yourself
You are not aware of the HbA1c blood test and how it monitors sugar levels over period of time
Concerns You are worried about diabetes affecting your eyes (typist) so you cannot work
You are worried that you will have poorly controlled diabetes like your mother. She had developed complications (gangrenous leg, blindness) as she did not take her medicines and has recently been moved to a nursing home as a result
Expectations You want to be given a home testing kit (glucometer) to check your sugar levels
You have no diabetic complications and are fully compliant with diet and medication advise
You deny any symptoms of thirst, increase urinary frequency, weight loss
You do not know what a hypo is, but deny feeling drowsy, confused, change in personality or hunger
You are not pregnant Medical history
Diabetes
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Drug history
Metformin twice a day (morning and evening). No previous allergies
Social history
You are married with 2 boys aged 10 and 7 respectively.
You work as a typist and your vision is essential to maintaining your job.
Your husband was recently made redundant and at the present time your income is barely covering the mortgage arrears
You do not drink alcohol or smoke cigarettes
Your diet has changed since you have been diagnosed with diabetes. You eat lots of fruit and vegetables and avoid cakes
Family history
Your mother suffers from blindness and had bilateral below knee amputations due to diabetic gangrene in Africa
When speaking about your mother you become emotional and expect the GP to show some empathy such as pausing, asking if everything is ok or offering some tissues. If they do so then tell them that your mother is now in a nursing home and has had two below knee amputations due to diabetic gangrene. Do not volunteer this information if the doctor fails to show empathy
If the GP is cagey or unsure what to do you should insist that you are prescribed the glucose kit
If the doctor does not give you a glucometer enquire why and attempt to get it on the NHS for free
If the doctor gives test strips attempt to get as many as possible on the NHS as you want to check your sugar levels 5 times a day.
If the GP is confident and explains that you do not need the kit as your sugars are well controlled you will be happy to accept their advice as long as he repeats your blood test in 2 months time or has regular quick blood tests (BM) at the surgery
Seek for an explanation of HbA1c
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CSA course case Request for test strips EXAMINER DATA GATHERING Positive indicators:
Gathers information and clarifies problem (request for BM monitor)
Establishes health problems of mother
Determines no symptoms of diabetes or pregnancy
Negative indicators:
Insufficient data gathering regarding diabetes or psychosocial history
INTERPERSONAL SKILLS Positive indicators:
Explores ICE (need for BM monitor, worry of blindness and developing ) and psychosocial history
Explores context of request mother has recently been taken into a nursing home
Picks up and addresses verbal (typist eye sight important to patient) and non-verbal cue
Empathise with the patients regarding her mothers poor health and admission to nursing home Negative indicators:
Does not pick up verbal or non-verbal cues
Fails to explore patients concerns about her diabetic control CLINICAL MANAGEMENT SKILLS: Positive indicators:
Advises that glucometer is not routinely available on NHS (patient can purchase from pharmacy)
Recommends patient that with type 2 diabetes limited evidence that home testing is necessary (especially with well controlled diabetes and lack of hypoglycaemic agents i.e. gliclazide / pioglitazone)
Negotiates with the patient not to prescribe tests strips as they are expensive. However if does offer test strips then provides accurate advice of self monitoring
Instead offers suitable explanation to decision making i.e. unlikely to have hypo with metformin
Explain that HbA1c better test for monitoring sugar levels over period of time (last 6 weeks)
Negative indicators:
Offers glucometer on NHS Offers test strips without explanation or recommendation of effective programme of management
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CSA course case CARDS
Vitals BP 125/65
Random BM 6.7
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CSA course case Request for test strips MX NOTES Blood glucose self monitoring Routine BM self-monitoring by patients is widespread despite there being a vacuum of supportive
evidence that shows an improvement glycaemia control especially in type 2 diabetics not on insulin
NICE do make an exception of self monitoring of plasma glucose in type 2 diabetics if it is an integral part of the patients self-management education. The purpose of self monitoring should be discussed and an agreement of how it should be interpreted and acted upon
It is appropriate for type I (or II diabetes), who have been initiated on insulin and need to adjust their dose according to the BM results. Also it can be used with diabetics with intercurrent illness
BM monitoring are useful to detect hypo (i.e. SE of medication) or hyperglycaemia and can help patients if educated what to do in such circumstances
Other instances where NICE recommend self monitoring include if the patient is on a hypoglycaemic agents and ensure safety during activities (driving)
If self-monitoring is indicated but blood glucose is unacceptable to the patient, NICE recommend considering the use of urine glucose monitoring
The British Diabetes Association has defined target values for fasting blood glucose levels as: self monitored blood glucose levels before meals of between 4 and 7 mmol/l
Typical schedule Below is a typical schedule to test sugar levels for a diabetic type 1. There is no recommended frequency of self-monitoring in type II diabetes
If patient has typically good BM control recommend to take twice a day with one at night before going to sleep and the other tested at different times on each day
Unwell patient who have poor control and experience recurrent hypo or hyperglycaemia should test their BM levels five times a day with the last being at the early hours of the morning i.e. 3am. This allows the checking of hypoglycaemia at night and for rebound hyperglycaemia in the morning