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Managing Clinical Problems in Diabetes, Case Study #8: Mr. TE

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mr. TE was an inpatient and was referred to a diabetes educator. Mr. TE is a 78-year-old man with type 2 diabetes who has a history of cancer and was referred because he is having trouble testing his blood glucose levels, especially obtaining enough blood….

He has:
  • Peripheral neuropathy
  • Peripheral vascular disease
  • Hypertension
  • Hyperlipidemia.
  • HbA1c is consistently ~7% and he takes particular care of his health.

Current medications

  • Xalatan eye drops (latanoprost)
  • Metformin 850 mg BID
  • Diabeta 2.5 mg if blood glucose > 180mg/dL. (10 mmol/L)
  • Verapamil
  • Lipitor (atorvastatin) dose not provided on the referral
  • Lactulose
He has trouble hearing.

His blood glucose lancet device is very dirty.

 
Diabetes educator

I would ask Mr. TE’s relatives to bring all his testing equipment in so I could check it and his testing technique. There may be an easier meter and fingerpricking device for him to use. I would check his vision. It sometimes helps if the fingers are warmed by gentle massaging in a downward way from the palm to the fingertip, or in warm water before testing. Waiting for a few seconds after pricking the finger before starting to squeeze a drop of blood sometimes helps, as does pricking on the fleshy part of the side of the finger. Keeping the hand lower than the level of the heart might also help.

Endocrinologist

The presence of peripheral neuropathy suggests his control may not be as good as the HbA1c suggests and careful correlation with fingerprick records is needed, and possibly fructosamine evaluation. Because of the peripheral vascular disease Mr. TE needs aggressive cardiovascular risk modification and vascular specialist assessment. Targets would include BP < 120/80, LDL < 78mg/dL (2 mmol/L), and excellent glucose control. I would not use metformin or Diabeta (glibenclamide) in a person in this age group but prefer shorter-acting sulphonylureas such as repaglinide or gliclazide, which carry a lower risk of hypoglycemia. If Mr. TE has significant hand neuropathic symptoms, which impair his dexterity, nerve conduction studies to exclude additional carpal tunnel syndrome would be warranted.

References

Anderson R, Funnel M, Arnold M (1996) Using the empowerment approach to help patients change behaviour. In: Anderson B, Rubin R (eds) Practical Psychology for Clinicians. American Diabetes

Association, Alexandria, pp 163–172. Bryden K, Dunger D, Mayou R et al. (2003) Poor prognosis of young adults with type 1 diabetes. Diabetes Care 26: 1052–1057.

Conrad S, Gitelman S (2006) If the numbers don’t fit . . . discrepancies between glucose meter readings and hemoglobin A1c reveal stress of living with diabetes. Clinical Diabetes 24: 45–47.

Coulter A (1997) Partnerships with patients: the pros and cons of shared clinical decision making. Journal of Health Service Policy 2: 112–121.

Fiandt K (2007) The chronic care model: description and application for practice. Topics in Advanced Practice Nursing eJournal 6(4): posted 5 January 2007.

Graue M, Wentzel-Larsen T, Bru E et al. (2004) The coping styles of adolescents with type 1 diabetes are associated with degree of metabolic control. Diabetes Care 27: 1313–1317.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Another Case Discussion

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath