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CANDIDATES BRIEF

Patient medical records

Name:

Patricia Amiobie (38 year old)

Past medical history: Diabetes

Drug history:

Consultation (2 weeks ago)

metformin 500mg bd

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

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 - CSA prep 2011

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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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CARDS
Vitals
BP 125/65
Random BM 6.7

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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

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CSA course case Request for test strips - CSA prep 2011