Type 1 Diabetes
Miss Trimble is a 21 year old Type 1 diabetic. She was diagnosed age 7. Her blood glucose and HbA1c have always been well controlled, though she was a bit overweight in her late teens. You now see that her HbA1c is 10. She has been missing appointments in secondary care. When she comes in you notice she has lost a lot of weight.
You ask her how she feels about that. She says she hates her body and wants to get under 7stone. She misses her insulin some days as she knows that makes her lose weight quicker. She is struggling to keep up with her College course. When she manages to lose weight she feels more in control of her life.
Try and put these facts into a Five Areas CBT model
Who could help this woman?
What skills will they need?
If they had helped her, how would you know?
Ischaemic Heart Disease
Mr Fry attends for his IHD review. His wife comes with him. She looks really worried.
It is 6 months since he was admitted with a myocardial infarction. He was immediately stented. He has been on his cardiac rehab course. His BMI is 25.5. He stopped smoking. His BP is 128/78. His pulse is regular. He tells you he never needs to use his GTN spray.
He looks worse than he did 6 weeks after his MI. He used to really enjoy golf and fishing. But since his MI he is afraid that if he had an attack at the far end of the golf course or the fishing lake, no-one would reach him in time.
Try and put these facts into a Five Areas CBT model
Who could help this man?
What skills will they need?
If they had helped him, how would you know?
Type 2 Diabetes
Mrs Drucker attends for your diabetic review. Despite increasing her metformin three months ago, her HbA1C has crept up to 8.0 and she has put on 7kg. Her BMI is now 40.1
She looks pasty and sad. She insists she does keep to her diet ‘Well, most of the time’. You ask about exercise and she says now her knees begin to hurt she doesn’t get out much. When you suggest she could try exercising in water she bursts into tears saying ‘It’s all my fault I’m like this’.
Try and put these facts into a Five Areas CBT model
Who could help this woman?
What skills will they need?
If they had helped her, how would you know?
COPD
You call Mr Pitman in for an early review as part of your pro-active care policy. Your practice manager has noticed he is attending the Walk in Centre a lot Out of Hours. His COPD is mild. Quite often the OOH doctors send him home with ‘reassurance’. Sometimes they give him antibiotics but the notes suggest this is done reluctantly. They seem to think his symptoms are due to overbreathing.
You ask him about smoking. He says ‘It’s the only thing that keeps me calm, doctor’.
Try and put these facts into a Five Areas CBT model
Who could help this man?
What skills will they need?
If they had helped him, how would you know?
Cancer
Mrs Parton seems to be at the surgery every week these days. She is 64 and was quite well until ten years ago when she had a breast tumour found on routine mammography. The tumour was 9mm in size, node negative, oestrogen positive. She completed all her treatment, including tamoxifen. She should have been discharged from the breast clinic after five years, but has opted to keep going back for ‘check ups’.
This time she has come to ask you about a lump on her back. You have a look and see it is a seborrheic wart. You begin to reassure her that it is harmless, but notice the tears in her eyes. You ask her what is really bothering her and she tells you she is frightened of dying. She checks her breasts every day for lumps and can spend an hour in front of the mirror after a shower.
Try and put these facts into a Five Areas CBT model
Who could help this woman?
What skills will they need?
If they had helped her, how would you know?
Asthma
The pharmacist has alerted you to the fact that 24year old Mr Westling has had twelve salbutamol inhalers in the last year. You bring him in for review and note that he has also been attending the Out of Hours service at the Walk in Centre complaining of ‘asthma’ and collecting inhalers there.
He isn’t on a preventer and when you ask why he says he is scared that steroids will do him harm. When you explore this further, he tells you that he gets very anxious about eating certain foods. He washes his hands several times after touching doorknobs as he is afraid of picking up a virus. He gets breathless in crowds and supermarkets. When he feels his chest going tight he takes his inhaler. He has noticed he needs to use it more and more these days.
Try and put these facts into a Five Areas CBT model
Who could help this man?
What skills will they need?
If they had helped him, how would you know?