Facilitator Notes Diabetes Part 2 CLG

Facilitator notes Diabetes part 2 CLG

1. Introductions5 mins

1. Introduce website5 mins

1. Thumbnail sketch case and learning outcomes of today’s session 5 mins

Learning outcomes:

First and second line oral medication.

Factors that influence choice of a particular medication.

Regimes, tds vs bd

Alternative meds e.g.: orlistat? Do they have a place?

(Consider motivational interviewing)

What about counselling, exercise regimes?

Complications of diabetes on other organ systems:

Need for retinal screening.

Use of podiatry, how to screen for foot care.

Use of micro -filament 10g, shoe advice.

Renal: implications of microalbumin, how to manage: medication, monitoring, BP control, medication.

Where to access information?

1. Divide into small groups – read the case and discuss the questions:

30 mins

Mr Kipling found the support he was given by the primary care diabetic service very helpful. At his diabetic review 6 months ago he was doing well. He appeared motivated and managed to lose some weight and increase his exercise.

He attends his follow up appointment with the Practice Nurse Sister Endive.

She does a pre consultation review of the notes. The last entry in is from 2 months ago when Mr Kipling saw the GP Registrar.

She learns that Mr Kipling was made redundant 5 months ago and that his daughter has had an admission for exacerbation of her asthma. His wife has had to work longer hours and he hardly sees her.

He has not been sleeping well and admits to snacking at night.

Today he is complaining of blurred vision and intermittent diarrhoea.

His results are as follows:

HbA1c 84

Creat 139

K+ 3.8

Na+ 140

Ur 10.3

Fasting glucose 11.7

eGFR 75

Microablumin: 2.3

LFT Normal

Total Cholesterol 4.7

Trigs 2.02

HDL 1.6

LDL 2.4

Ratio 2.93

BP 153/81

Weight 102

Waist circumference 123cm

BMI 39.8

Medication: Atorvastatin 40mg; Citalopram 10mg

Discussion:

• Think about how you would you approach the consultation?

What could be the causes for such a change?

In your role is there any aspect of the discussion that you would find difficult?

• In your role what are the frustrations for you in dealing with diabetic patients who do not appear to be engaging with the management of their diabetes? How do you recognise and deal with this while also trying to facilitate behaviour change?

• Think about medication options. Would you choose a particular medication over another? Why? Pros and Cons. What follow up or support would he need?

• Are there alternative approaches to simply more tablets or medication?

In the first set of questions, choose which ones are of most relevance to your group if you do not have time for all of them.

Some questions are on clinical aspects, while another is on behaviour change and exploring factors that influence this.

You may not have time to do everything.

You may choose to go down the route of Motivational Interviewing.

This is about exploring whether someone wants to change and exploring with them the perceived consequences or advantages of not changing and the implications and possible advantages of changing.

In part 2 of the scenario, consider that the patient may have Erectile Dysfunction (the something Mr Kipling wants to talk to the nurse about)

You may wish to do this as a role play

Sister Endive is worried about Mr Kipling. She asks him to come back for review in 3 months.

He seems a little brighter but clearly has something he wants to ask you.

Three months later his results are as follows:

HbA1c 62

Creat 186

K+4.0

Na+ 142

Ur 14.2

eGFR 56

Microalbumin: 14.8

LFT normal

T.Chol 3.9

Trigs 1.80

HDL 2.0

LDL 3.4

Ratio 1.95

BP 139/80

Weight 96kg

• Think about the type of discussion would you have with Mr Kipling? Is there anything specific you would like to ask him?

• How would you manage him at this stage? Are you concerned about any other complications? If so which ones? How would you manage each?

Sister Endive is still concerned about Mr Kipling and asking to come back in another 3 months. This time when you see him he is positively cheerful, he has had a complete change of career, he is now a garden designer and is enjoying being outside and doing something practical. His relationship with his wife has improved and he thanks you for the tablets you gave him.

He has also started doing some voluntary work for with a ‘Friendly Neighbour” scheme driving the elderly to hospital appointments.

You explain to him that you would like to examine his feet. He is a bit reluctant; he wears boots all day and says his feet are “not very pretty”. He removes his shoes.

You see a thick toenail and wet excoriated skin between his toes. There is also a very thick area of skin on the sole of his left foot. The skin on the dorsum of his feet and lower leg is dry. He has a very small-ulcerated wound on the sole of his right foot beneath the big toe. You ask him how long he has had the ulcer but he doesn’t know what you are talking about.

Results:

HbA1c 59

Creat 223

K+ 5.1

Na+ 143

Ur 16.8

eGFR 32

Microalbumin: 26.3

T Chol 4.1

Trigs 1.98

HDL 2.0

LDL 2.9

Ratio 2.05

BP 137/78

Weight 88

Retinopathy report: pre proliferative retinopathy both eyes

• What next?

Is your discussion going to be different to previous ones?

Talk about what you might find difficult.

Are you concerned?

How do you share your concerns with Mr. Kipling?

• What are the long-term issues for his health, does he have any predictors for CV health? What are they and how would you manage them?

• Can we continue to manage in primary care or do we need secondary care input?

• Are there any medico legal considerations? Do you need to give him any specific advice? If so what is that advice? Are there any resources you can access to help you?

• What medication challenges does this create? Why?

1. Plenary35 mins
2. Information Giving & Close10 mins

We are hoping to have secondary care representation at the meetings and if we receive any information in advance we will forward this on.