Learning Disability: Diabetes

Plabforum · November 15, 2023, 9:34am

You are an FY2 in GP.

Mr. James Atkinson, aged 24, was diagnosed with Type 1 diabetes two months ago after he
had an episode of DKA. He was admitted and managed in the hospital. He was put on a
short-acting insulin three times with meal and long-acting insulin before going to the bed.
The diabetic nurse has been going to his house to check the blood glucose and on 2
occasions they were on the higher side.

Talk to him and address his concerns.

Note: The patient has a learning disability.

D: What brings you in?
P: I am here for my diabetic review.
D: Since how long have you been diagnosed with DM?
P: For 2 months.
D: How are you managing it?
P: Insulin.
D: Are you taking them as prescribed?
P: No, I take it when I have sugary meal.
D: May I know why?
P: This is what I understood the last time I saw the doctor.
D: Any symptoms of DM?
P: Like what?
D: Feeling thirsty?
P: Yes
D: Going to the loo more often?
P: Yes
D: Do you check your blood sugar regularly?
P: No
D: Any complications of DM?
P: Like what?
D: Any problem with the foot?
P: No
D: Any problem with the vision?
P: No
D: Any chest pain?
P: No
D: Do you see your GP regularly?
P: Yes
D: Have you been diagnosed with any medical condition?
P: No
D: Are you taking any medications including OTC or supplements?
P: No
D: Any allergies from any food or surgeries?
P: No
D: Any previous hospital stays or surgeries?
P: No
D: Has anyone in family been diagnosed with any medical condition?
P: No
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet?
P: Good/Bad
D: Do you do physical exercise?
P: Good/Bad
D: What do you do for a living?
P: I work from home
D: Who do you live with?
P: Alone
D: Any family nearby?
P: Yes my parents.
D: Is it stressful?
P: Yes/No

I would like to check your vitals and do the GPE.
I would like to send for some initial investigations including routine blood tests, U&E, LFT’s,
blood sugar and HbA1c.

Examiner: Examination Normal.

From our assessment, your DM is not well controlled as you are drinking water more than
usual and going to the loo more often. You are also not taking the insulin as prescribed.

We will do a routine blood test to check cholesterol level, sugar level and kidney and liver
function. We will also do a special blood test to know the level in the last 3 months. We will
also do a urine test.

It is very important to take your insulin regularly as we prescribed. If you do not take it
regularly as prescribed, your blood sugar cannot be controlled. You have to take the insulin
3 times a day, before breakfast, before lunch and before dinner. You have to take one insulin before going to sleep. Please make sure that you do not miss any of your meals and
also do not forget to take the insulins.

If you do not follow this, DM can cause damage to large blood vessels and can cause kidney
problems, heart disease and high blood pressure. DM can cause damage to small blood
vessels at the back of your eyes and can cause vision problems. It also affects the nerves of
your feet. Missing insulin dose is one of the most common causes of DKA which you had in
the first place.

Smoking:
Smoking can damage the inside of the walls of blood vessels and narrow them. I know it is
not easy to stop smoking but we are here to help you. We can refer you to the smoking
cessation clinic, they will do their best to help you to stop smoking by using different
methods. There are nicotine replacement products - including patches, gum. lozenges and
mouth and nasal sprays.
We can also provide with some tablets (varenicline and (bupropion).

Diet:
I understand that you have a busy life but it is very important to have a sensible diet. Having
a healthy diet will help in controlling your weight and reduces the risk of further
complications. Eating out is not healthy as they use a lot of salt, sugar and fat to make it
tastier. I understand it may be difficult to cook every day but you can cook once or twice
per week and use it for the whole week. So you don’t have to eat outside every day.
Please cut down the amount of red meat and processed meat such as sausages and bacon
and try to have white meat such as chicken and fish instead.
It is also better to have grilled, steamed or boiled food rather than fried food.
We can also refer you to a dietician who can help you better.

Physical activity:
It is advisable to have at least thirty minutes of physical activity every day five times a week.
You don’t necessarily have to go to the gym. It shouldn’t be in one session, it could be split
into two sessions of fifteen minutes or three sessions of ten minutes. For example if you use
public transport, you can get off one to two stops before reaching home and you can walk
instead. If you drive, please walk when you going to buy something from your local shop. If
you live in a flat, you can climb the stairs instead of using the lift.

Stress: Stress could worsen your condition. So it is important to relieve your stress. You may
try doing some physical activities such as walking, jogging or swimming. In this way you can
relive your stress and relax yourself. You may also try taking yoga classes.

Alcohol: It is always advisable to cut down the amount of alcohol you take. The
recommended daily amount of alcohol is 2 units per day. I know it is not easy to cut down
but we are here to help you. We can refer you to our colleagues, they will do their best to
help you to cut down your alcohol.

Plabforum · November 15, 2023, 9:44am

	Insulin Learning Disabilities
Station	FY2 in the MOPD. John Smith a 34yo man who has come for a review. He had presented to the hospital 2weeks ago with DKA for the first time and he was diagnosed with DM1. He was started on insulin. Short acting insulin (Actrapid) 3times/day with meals and long acting insulin (Lantus) once in the evening. The district nurse usually helps him with insulin administration. His blood glucose is 11mmol/L. Review the patient and address any concern.
Patient info	You were diagnosed with DM1 3weeks ago. today you are here for follow up. You were prescribed types of insulin. Short acting insulin times with meals and long acting insulin. You have learning difficulty. You have a district nurse who comes and helps you to take insulin. You are slow in understanding the information and you keep asking the same Q to the Drs because you are finding it difficult to remember things. You only take insulin when your glucose is high. You are happy if the Dr says he will write down everything for you.
Intro	I understand that you are here today for follow up. Am I right? Also, I see that you were diagnosed with DM1 2 weeks ago. can you please tell me more about it?
History	DM Itself: Since when have you been Diagnosed with DM? is it DM1 or DM2? how is your diabetes? Do you measure your blood sugar? Is it controlled or not? Do you take any medication for it? How are you coping with it?
	Medication: If yes (what medication? what is the dosage? do you take it as prescribed? do you review your medication with your GP?) Do you check your blood sugar regularly?
	Complications: Do you have complications (problem with your vision? pain while passing urine? chest pain or problems with your heart? numbness or tingling in your hands or feet?)
concern	Do you have any concern regarding DM?
P2	Have you experienced such episode before? Apart from DM, have you been diagnosed with any other Medical conditions?
Р3	DESA, MAFTOSA (Job) (insulin dose) (Social) (Driving)
Finishing Hx	Thank you for answering my Questions
Expectations	What do you expect from today’s visit?
Examination	Observations + Chest + Legs+ Eyes
Ideas	Do you have any idea what is DM? has anyone explained it to you?
Provisional diagnosis	Unfortunately, the blood sugar is on the higher side and this is because you were not taking your insulin as prescribed.
Management	NB/ BE slow + Don’t use medical jargons + write down instructions on how to take insulin
	Explain the Meds: (you should check blood sugar before administering insulin); Short acting inulin (Actrapid): works for a short time + taken 3times/day + taken 30min after eating; long acting insulin (Lantus): Works for a longer time + taken at night to control blood sugar till morning
	Advice: Discuss diet and give dietary advice considering other factors like obesity, HTN, Renal impairment (offer referral to the dietician)
	Advice that regular physical activity can reduce arterial risk in the medium to long term and where appropriate, discuss adjustments to insulin regimen or calorie intake during exercise. Ask the patient to consider wearing a medical emergency identification bracelet or similar. If appropriate, advice of the need to contact the DVAL to inform them of the diagnosis Advice patient to carry insulin in their hand luggage if they are travelling Advice that she is reviewed by the diabetic nurse to explain the medication.
	Inform Senior; Safety netting: sweating, fever, fainting
Closure	Please at any time if you have questions or concern, let us know

Plabforum · November 15, 2023, 10:02am

Who you are: You are an FY2 in GP clinic.

Who the patient is: Matt Albertson, aged 24, was diagnosed with Type 1 diabetes two months ago after he had an episode of DKA. He was admitted and managed in the hospital. He was started on a short-acting insulin three times with meal and long-acting insulin before going to the bed.

Additional information: The diabetic nurse has been going to his house to check the blood glucose and on 2 occasions they were on the higher side.

What you should do: Talk to him and address his concerns.

This is a very basic counselling station but what you need to consider is the following:
− The patient may be slow of understanding, don’t rush the patient, go at his own pace.
− Use easy terminology, repeat and make sure he understands.
− Explore what difficulties he has.
− Explore the social support around him.
− Watch your language and don’t offend the patient.

D: Hello I am one of the doctors here in the GP clinic. Am I talking to Matt?
P: Yes.
D: Can I get your full name and date of birth please.
P: (Confirms details)
D: How can I help you today?
P: I am here for my diabetic review.

Explore DM as before
P1 Explore DM:
D: For how long have you been diagnosed with DM?
P: For 2 months.
D: Do you take any treatment for it?
P: Yes I take insulin.
D: Do you follow the doctor’s advice about how to take it?
P: Yes doctor I take it after sugary things and sweets, to keep my blood sugar low as my doctor told me last time.
D: Is that what the doctor told you last time you were here?
P: Yes doctor.
D: Do you remember the dose?
P: Sometimes I get confused with it doctor.
D: Is your blood sugar well controlled?
P: I don’t know doctor.
D: Do you check your blood sugar regularly?
P: The nurse checked it for me twice.
D: When was the last time you measured it yourself?
P: When she came 4 days back.
D: Have you been regularly following up with your GP?
P: Yes.
D: Have you had any bothering symptoms lately? Open Q
P: …

DM Sx
D: Any excessive feeling of thirst?
P: Yes most of the time.
D: Do you go to loo more often than usual?
P: Yes a lot doctor I hate it.
D: Have you lost any weight recently?
P: I don’t know.

DM complications:
D: Any problem with vision?
P: No.
D: Any unusual sensation in any of your hands or feet?
P: No.
D: Any pain while passing urine?
P: No.
D: Any chest pain or feeling like your heart is racing?
P: No.
D: Do you sometimes feel dizzy or about to pass out after your insulin?

P2:
D: I can see from my records that you were here 2 months back do you remember what happened?
P: Yes doctor I had very bad tummy pain, they told me I have high blood sugar and that I have to take these injections.
D: Do you have any other medical conditions?
P: No.
D: Any previous hospital stays or surgeries?
P: No.

MAFTOSA
D: Do you take any medications ?
P: No.
D: Do you have any allergies?
P: No.
D: Do you have any similar health problems in your family?
P: No.
D: Who do you live with?
P: I live alone.
D: Do you have any family nearby? (Watch out when you ask this Q do not say who take cares of you, he is a grown man).
P: Yes my parents, they check up on me every now and then.
D: What do you do for a living?
P: I work from home.
D: How have you been feeling lately? Do you feel stressed by any chance ?
P: Yes, I am a bit stressed because I don’t want to get sick again like what happened before.
D: That’s wise of you to care about your health.

Explore the disability: You will have to exercise very good active listening and a decent choice of words.

D: You mentioned that sometimes you get confused with the dose of your medications right? Can you tell me more about that?
P: (…) (Whatever he says you consider in management.)

Possible difficulties:
“Sometimes people taking the same medicine may struggle a bit in the beginning because they do not…”
− Remember to take it (Forgetful of the time)
− Remember or understand the doctor’s advice because he might be talking quickly and it’s a lot to take in when explained for the first time.
− Understand when reading instructions … or cannot write notes to remind themselves…etc

Other difficulties:
• It might be painful injecting so many times.
D: Do you have any concerns you want to talk to us about ?

DESAS:
D: Tell me about your diet?
P: Good/Bad
D: Do you do physical exercise?
P: Good/Bad
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No

Examination:
Thank you for attending your follow up today. To complete it I would like to check your observations. I will do a general physical examination including checking your heart and tummy and I will take a look at your feet as well. I will check your weight and height (to calculate your BMI).
We will also measure your blood sugar level now. Would that be okay?

Provisional Diagnosis
Thank you Matt for bearing with me. Now let me try and explain alright?
Our nurse has visited you twice over the last month, and she found out that your blood sugar is still higher than usual when she measured it. Do you remember her visits?
P: Yes.

Well From our chat as well you mentioned you are always thirsty and that you go to loo often, right?
We suspect that your blood sugar is not well-controlled, especially when you take your insulin only after sugary food. And that will make the condition you have, which is called Diabetes, get worse. Am I going to fast?
P: No doctor, so what are you going to do?

Management:
Advice and Risk factors:
D: I appreciate that you were doing your best to take the insulin, but you were still struggling a bit. How about I revise with you when and how to take it to control your blood sugar better? Would you like that?
It is very important to take your insulin regularly not only after sugary food. You have to take the insulin 3 times a day, every day, before breakfast, before lunch and before dinner. You have to take one insulin before going to sleep. Make sure that you do not miss any of your meals or your insulin, otherwise your
Diabetes will not be controlled and you will feel sick again.
Always keep something sugary with you and if you feel dizzy after insulin, eat
it.
We will give a bracelet to let doctors know that you are on insulin just in case
you feel sick suddenly.
P: But I sometimes forget my doses doctor:
D: Options:
− You can remind yourself by writing a note or putting an alarm on your phone(ask if he can use a mobile).
− Take it just before each meal as I mentioned.
− Your family members can help remind you.
− A GP reminder call.
− We can send the Diabetic nurse every now and then to remind you how and when to take it.
− You can call the GP the any time if you have any queries.
How do you feel about all that?

Management: (Inv + senior)
We will do a routine blood test (cholesterol level/sugar level/kidney/liver function/HbA1c/ urine test)

DESAs ADVICE

Exactly as before.
You mentioned you feel stressed more than usual and it can have a bad effect on DM. We are here to help you at every step. Try talking to your family and friends. Try doing some physical activities such as walking, jogging or swimming. In this way you can relive your stress and relax yourself. You may also try taking yoga classes.
P: How dangerous is DM doctor?
D: DM can cause damage to large blood vessels and can cause kidney and heart disease and high blood pressure. It can cause damage to small blood vessels at the back of your eyes and can cause vision problems. It also affects the nerves of your feet. Missing an insulin dose is one of the most common causes of DKA which you had in the first place.

MDT and Diabetic clinic: As before.
Safety net: Hypoglycemia and DM complications.

Plabforum · November 15, 2023, 10:18am

You are an FY2 in GP. Mr James Atkinson, aged 24, was diagnosed with Type 1 Diabetes two months ago after he had an episode of DKA. He was admitted and managed in the hospital. He was put on a short acting three times with meal and long-acting insulin before going to the bed. The diabetic nurse has been going to his house to check the blood glucose and on 2 occasions they were on the higher side.

Talk to him and address his concerns. Note: patient has a learning disability.

D: What brings you in?
P: I am here for my diabetic review.
D: Since how long have you been diagnosed with DM?
P: For 2 months.
D: How are you managing it?
P: Insulin.
D: Are you taking them as prescribed?
P: No, I take it when I have sugary meal.
D: May I know why?
P: This is what I understood the last time I saw the doctor.
D: Any symptoms of DM?
P: Like what?
D: Feeling thirsty?
P: Yes
D: Going to the loo more often?
P: Yes
D: Do you check your blood sugar regularly?
D: Any complications of DM?
P: Like what.
D: Any problem with the foot?
P: No.
D: Any problem with vision?
P: No
D: Any chest pain?
P: No
D: Do you see your GP regularly?
P: Yes
D: Have you been diagnosed with any other medical condition apart from DM?
P: No
D: Are you taking any medications including OTC or supplements?
P: No
D: Any allergies from any food or medications?
P: No
D: Any previous hospital stay or surgeries?
P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: No
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet?
P: Good/Bad
D: Do you do physical exercise?
P: Good/Bad
D: What do you do for a living?
P: I work from home.
D: Who do you live with?
P: Alone
D: Any family nearby?
P: Yes my parents
D: Is it stressful?
P: Yes/No

I would like to check your vitals and do the GPE.
I would like to send for some initial investigations including routine blood tests, U&E, LFT’s blood sugar and HBA1C.
Examiner: Examination Normal
From our assessment, your DM is not well controlled as you are drinking water more than usual and going to the loo more often. You are also not taking the insulin as prescribed.

We will do a routine blood test to check cholesterol level, sugar level and kidney and liver function. We will also do a special blood test to know the level in the last 3 months.
We will also do a urine test.

It is very important to take your insulin regularly as we prescribed. If you do not take it regularly as prescribed, your blood sugar cannot be controlled. You have to take the insulin 3 times a day, before breakfast, before lunch and before dinner. You have to take one insulin before going to sleep. Please make sure that you do not miss any of your meals and also do not forget to take the insulins.

If you do not follow this, DM can cause damage to large blood vessels and can cause kidney problems, heart disease and high blood pressure. DM can cause damage to small blood vessels at the back of your eyes and can cause vision problems. It also affects the nerves of your feet. Missing insulin dose is one of the most common causes of DKA which you had in the first place.

Smoking:
Smoking can damage the inside of the walls of blood vessels and narrow them. I know it is not easy to stop smoking, but we are here to help you. We can refer you to the smoking cessation clinic, they will do their best to help you to stop smoking by using different methods. There are nicotine replacement products - including patches, gum, lozenges and mouth and nasal sprays. We can also provide some tablets (varenicline and bupropion).

Diet:
I understand that you have a busy life but it is very important to have a sensible diet. Having a healthy diet will help in controlling your weight and reduce the risk of further complications. Eating out is not healthy as they use a lot of salt, sugar and fat to make it tastier. I understand it may be difficult to cook every day but you can cook once or twice per week and use it for the whole week. So you don’t have to eat outside every day.

Please try to have plenty of fruits and vegetables in your diet. Fruits and vegetables are a vital source of vitamins and minerals and should make up just over a third of the food we eat each day.
Please cut down the amount of red meat and processed meat such as sausages and bacon and try to have white meat such as chicken and fish instead.
It is also better to have grilled, steamed or boiled food rather than fried food.
We can also refer you to a dietician who can help you better.

Physical activity:
It is advisable to have at least thirty minutes of physical activity every day five times a week. You don’t necessarily have to go to the gym. It does not need to be in one session, it could be split into two sessions of fifteen minutes or three sessions of ten minutes. For example, if you use public transport, you can get off one to two stops before reaching home and you can walk instead. If you drive, please walk when you go to buy something from your local shop. If you live in a flat, you can climb the stairs instead of using the lift.

Stress:
Stress could worsen your condition. So, it is important to relieve your stress. You may try doing some physical activities such as walking, jogging or swimming. In this way you can relieve your stress and relax yourself. You may also try taking yoga classes.

Alcohol:
It is always advisable to cut down the amount of alcohol you take. I know it is not easy to cut down, but we are here to help you. We can refer you to our colleagues, they will do their best to help you to cut down your alcohol.