Dr Jon Tuppen GPSI Diabetes

Consider this case ♂ DOB 14.5.57 14 May 2007 15:28  Smoker (137R.) "6-7 a day“

had a routine taxi driver medical examination - letter from Dr. Coull, had high B.P readings - 175/120, and 2+ of sugar in urine, no symptoms, not on any medication @ present, going through very stressful period . o/e - B.P - 175/112, H.R - regular, Chest - HS - normal, no murmuradvice to get bloods done including fasting glucose, Hba1c, repeat B.P readings on 2 different occasions with nurse 1 wk apart, ECG , start on lisinopril tablets 5mg & r/w in 3-4 wks time. Smoking cessation advice (Ua1Nz)

 what would you have done from here?What is the diagnosis?

BloodsSerum glucose level (44f..): 6.60 mmol/LSerum creatinine level : 120.00 umol/LSerum cholesterol level : 6.00 mmol/LSerum sodium level : 139.00 mmol/LSerum albumin level (XE2eA): 46.00 g/LSerum globulin level (XE2eB): 25.00 g/LALT/SGPT serum level (44G3.): 88.00 iu/L

Surgery 05 Jul 2007 14:16

 

Alcohol units (Ub171): 6.0 Units/WeekEx-smoker (Ub1na)Requested note for work regarding "fit" to work. He has just been informed if he doesn't get a letter today he would loose his job as a taxi driver. Bp- 168/118, 169/113 , 167/109 . Appt made to see GP.

 

Serum HDL cholesterol level (44P5.): 0.92 mmol/L

Serum LDL cholesterol level (44P6.) "Specimen unsuitable for LDL Cholesterol due to high triglyceride concentration."

Serum cholesterol level (XE2eD): 6.90 mmol/L

Serum triglyceride levels (XE2q9): 7.21 mmol/L

Serum cholesterol/HDL ratio (XaEUq): 7.50

HbA1c level (DCCT aligned) (XaERp): 6.1 %

CVD risk assessment done (10yr value) (Y04e8): 32.43 %

Surgery 07 Nov 2007 11:58O/E - Diastolic BP reading (246A.): 104 mmHgBody mass index - observation (22K..): 34.77 Kg/m²O/E - weight (22A..): 119.000 Kg (18 st 10 lb)O/E - Systolic BP reading (2469.): 146 mmHgNotes BP review - high risk pt, obese BMI 34, HTN, Impaired fasting

glycaemia, Hyperchol, still smoking!, taxi driver.Discussed CV risks and strategies. 32%. Smoking - has contacted cessation service, but not followed up. BP 154/113 - repeat slightly better.BMI - taking exercise, agreed for prescription for health, due to see dietician shortly. BP still high - inc lisinopril to 20mg od. Repeat bloods, to call for results. Review in 1/12 - consider antiobesity med.CR 120 - eGFR 60,54.

amlodipine tablets 10mgatorvastatin tablets 10mglisinopril tablets 20mg

Surgery 29 Sep 2008 09:07

“thinks is diabetic. Polyuria and polydypsia for 6/52 with assoc wt loss, feeling tired. FHx of DM -father, grandparents. d/w pt significance and pts understanding. Keen for testing. Sent for fasting bloods U&E, LFT, Chol, Glu, TFT, FBC. r/v with results”.

Serum glucose level (44f..): 20.50 mmol/LUrea and electrolytes (X77Wi)Serum sodium level (XE2q0): 139.00 mmol/LSerum triglyceride levels (XE2q9)Serum triglyceride levels (XE2q9): 105.15 mmol/LBiochemical test (X77W9) "Sodium and potassium done by direct ISE. TRIGLYCERIDE AND GLUCOSE PHONED TO SURGERY 06/10/08. SUGGEST URGENT REPEAT TO ASSESS LIPID AND GLUCOSE LEVELS."

Engaged empowered patient

Organised

proactive system

Partnership

= Better outcomes

In England : The Diabetes NSF

Internationally: The Chronic Care Model - Wagner

had at least one check up in the last 12 months

and

discussed ideas about the best way to manage their diabetes

agreed a plan to manage their condition over the next 12 months

discussed their goals in caring for their diabetes

From ‘Managing Diabetes’ Healthcare Commission: 2007

NHS Next Stage Review “High Quality Care For All” commitments:

• By 2010 all 15.4 million people with a long term condition will be offered a personalised care plan.

• A new Patients’ Prospectus will provide people with long-term conditions information about the choices that should be available locally to enable them to self care in partnership with the health and social care professionals

Personalised Care Planning and the Patients’ Prospectus

...the individual, their needs and choices at the

centre of the process. Goal setting to support

people to achieve outcomes such as walking unaided or return to work

…includes helpful and relevant information,

through an Information Prescription, for

example about conditions, treatments, care services, benefits,

and support groups.

…includes support for self care. The Patients’

Prospectus will drive demand for self care

services such as access to peer support networks,

generic or disease specific courses, tools and devices and healthy living advice.

Promotes choice.…coordinated services for those that need it, contingency planning. Action planning and

review. Results in a single overarching care plan

Individualised services, meeting

holistic needs. Wider choice

supports commissioning

decisions

A process of discussion, negotiation and shared decision making that takes place between the person and their professional who

have an equal partnership

Care Planning – the National Messages ……

Personalise

d Care Planning

Task: Design from scratch a diabetic system for your practice and consider how it integrates with other parts of local diabetes careConsider things like

AdminWho does whatWhen will be it be heldWhere will be it be held AuditWho else do you need to

involve?Education of workforceWho has main

responsibility?etc

Consider from the patients sideWhat will you want ?What information do you

need?What will you main

concerns be?Time commitment on

diabetes careImpact on work/ family /

insurance etc