Who you are:
You are working as a Foundation Year 2 doctor in GP SurgeryWho your patient is:
Mr. Arnold Pearson, a 56 old man who has come for annual review.Other information you have about the patient:
Patient has had diabetes type 1 for the past 10 years and he is on Insulin.
HbA1c last year 62mmol/L
Eye examination demonstrates dots and blots hemorrhages.
He is awaiting review by the ophthalmologist.What you must do:
Take a focused history, perform relevant examination and discuss management with the patient.
Patient Information
You have had burning sensation for long time
You take Insulin
You have had diabetes for the past 10 years
You have blurry vision.
On Examination:
Loss of sensation below mid-shin bilaterally
His gait was high stepping gait.
Questions
What are you going to do for me?
What is wrong with me?
Who you are:
You are working as a Foundation Year 2 doctor in a general medicine out-patient clinic.Who your patient is:
Mr Robert Smith, a 40-year-old gentleman who has come for annual review.Other information you have about the patient:
He has had Diabetes Mellitus for the last 5 years. 10 months ago he had some HbA1c tests done which were as follows:HbA1c is 72% (normal HbA1c is <48mmol/L)
Neurological examination was normal.What you must do:
Examine the lower limbs, perform examination of the lower limbs and discuss management with the patient.
Who you are:
You are working as a Foundation Year 2 doctor in GP SurgeryWho your patient is:
Mr Robert Smith, a 56-year-old gentleman who is known diabetic type-1. He is on insulin but does not take this medication regularly. He is also not going for regular follow up.Other information you have about the patient:
URINE ANALYSIS
Glucose ++++
Protein +++
Ketones +ve
Nitrites –ve
Fundoscopy Dot and blot haemorrhagesOn examination:
Loss of touch sensation upto the knees bilaterallyObservations
BP 140/80, HR 89, RR 14,. T 36.7He has been referred to the opthalmologist but he is still waiting for the appointment.
What you must do:
Take a focused history to assess for the complications of diabetes. Talk to patient about life style changes, advise him to go for ophthalmology follow and discuss further management with the patient.
Patient Information
- Opening sentence: Doctor I’ve got this funny feeling in my legs.
- Jane/Robert Smith, 40 year old man. You have had diabetes for the past 5 years which is diet control only.
- The doctor is coming to take a history from you
- You are lying on a hospital bed and you are wearing a hospital gown
- You do not know your normal blood sugar levels
- Your last annual review was 3 years ago
- You were referred to the ophthalmologist but you never went for the appointment.
- You have tingling or numbness in your legs
- And sometimes your feet feel cold
- You are worried about amputation because a friend of your with diabetes had an amputation due to complications
- You have loss of all modality of sensations below the mid shin
- You have a glucometer; you know how to use it but you do not always use it
- You have got diabetes
- You take simvastatin once a night for high cholesterol
- You are married with 2 children
- You live with your wife/husband
- You are both retired. You used to work as a bus driver and your partner used to work as a school teacher.
- You take a dog for a walk everyday but lately you have been finding it difficult due to these pins and needles in your legs.
- Both of your children are grown up and live on their own
- Today you have come for your annual follow up because you are scared of having amputation of your legs.
- When the doctor examines you, you have loss of sensations below the mid shin on both legs and fungal infection between the toes.
Scenario A:
- You have diabetes Type II that is on diet control.
- On Examination:
- You have got loss of all sensation modalities upto knee level on both legs.
- All observations are normal
Scenario B:
- You have insulin dependent diabetes.
- You are on insulin long acting (actrapid once a day in the morning) and short acting (novrapid 3 times a day).
Scenario C:
- You have got non-insulin dependent diabetes.
- You are taking Metformin 500mg twice a day
Scenario D:
- Patient opening sentence “ I’m here to be told off”
- Doctor: No, I will not be telling you off ,we are just going to have a chat about what you need to do”
Questions:
- Will the same thing happen to me like my friend?
- Is everything fine doctor?
- What are you going to do for me?
- What is the worst thing that can happen to my legs?
Scenario E:
- Everything is normal, no sensory loss of the legs and you are not worried about anything.
Setup
Equipment:
- Tuning Fork 128Hz
- Cotton wool
- Neuropin
- Tendon hammer
- Sharps bin
Emotions and attitudes: Normal
Examiner’s prompt:
- If the candidate wants to perform Fundoscopy (eye examination) tell them fundoscopy is normal
- Patient should have loss of sensation below the mid shin bilaterally and fungal infection between the toes.
Approach
- GRIPS- Loud, confident, smile, shake hand, maintain eye contact.
- Paraphrase:
- I understand you have come for routine follow-up.
- How are you doing?
- Do you have any concerns since your last annual review?
- History of diabetes:
- How long have you had diabetes?
-Which type of diabetes do you have? - Are you on any regular medications?
- Are you compliant to your medications?
- Is your Diabetes well controlled?
- How often do you check your blood sugar levels?
- What are your normal blood sugar levels?
- When was your last annual review?
- How have you been since your last annual review?
- Were you referred to the opthamologist and were you referred for your annual eye check up.
- Is he under the specialist review?
- How long have you had diabetes?
- History of complications;
- Diabetic retinopathy Any visual problems?
- Peripheral Neuropathy Any numbness, tingling or burning sensation in the feet and hands?
- Diabetic nephropathy- any swelling of legs or face?
- Ask about complications:
- IHD
- stroke
- intermittent claudication- any pain in your legs while walking?
- Lifestyle (few questions regarding lifestyle)
- Regular feet inspection
- Do you smoke?
- Do you drink alcohol?
- diet –
- How is your diet?
- Have you ever been referred to a dietician?
- Do you normally do exercise
- General Health: Do you have any other medical problems other than diabetes?
- Is there any particular thing that you are worried about?
- Reassure them
- I will examine you and I will feel your feet.
- Give advice on how to prevent the complications
Examination
Take permission from the patient before you begin.
- Gait + look inside and on the side of the shoes
- Have a look inside the shoes and under the sole as well.
- inspection
- check the soles (pressure ulcers) and between the toes (fungal infection).
- temperature
- tenderness (calf)
- pulses – Dorsalis pedis artery, posterior tibialis artery.
- CRT (press for 5 seconds)
- Neurological (touch sole with monofilament, pinprick,position, vibration, reflexes).
Management
- Explain the findings to the patient i.e. loss of sensations on the sole and upto knee or midshift or ankle or both sides
- You can sustain cuts or break wihtout knowing about it. This condition is called diabetic peripheral neuropathy.
Diabetic foot care:
- Inspect the feet daily-any swelling, skin breaks, colour change, any numbness. Sometimes it might be difficulty see the bottom of feet, you can try and use a mirror.
- Cuts or wounds may go unnoticed so advise to inspect feet regularly
- Foot wear: comfortable shoes
- Avoid walking bare footed
- Refer to podiatrist ( would you be happy if I refer you to these specialist?)
- Advise to control blood sugar
- Wash feet everyday and make sure you dry them
Perform Investigations:
- Hb A1C: Will show the blood glucoese control ver 3 months period
- Observations:Blood pressure,pulse
- Fundoscopy: to check for any changes at the back chamber of the eye.
- Blood tests (FBC, U&Es)
- ECG
- Refer to ophthalmology, if he has not been referred.
7:Urine test (to check if he is losing any proteins in the urine which may suggest kidney problems)
Lifestyles changes
- Smoking
- Exercise
- Alcohol.
Referral to diabetic support group
Refer to a diabetic nurse
Refer to the ophthalmologist.
Advice about balanced diet.
Offer a diet sheet.
Offer leaflets about diabetic foot complications.