Ms Hooper is a woman with type 1 diabetes. Control of her blood sugar has been consistently poor, and the Diabetes Nurse Specialist thinks she rarely administers her full daily insulin requirement. Her HBA1c is 85 mmol/mol. She has had no retinopathy or macrovascular/microvascular complications. However, this is her third admission this year with diabetic ketoacidosis. Furthermore, blood tests have revealed a raised ALT (99) and GGT (277) and an ultrasound of the liver shows it is enlarged with fatty infiltration. Discuss the likely diagnosis of non-alcoholic steatohepatitis and explain the need for tighter sugar control.
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A good candidate will introduce themselves and establish thereas ons for the consultation. The candidate will explore the patient’s current ideas about their diabetes and will explore their concerns about using insulin and why they may not be adherent. The candidate should explore the impact diabetes has on the patient’s life, including driving, alcohol, education/work. The candidate would be expected to give some basic insulin counselling, explaining that there are different options available to manage diabetes. The candidate should explain the importance of insulin in the short term (DKA) and the long term (neuro, vascular complications). A good candidate will arrange follow-up with the Diabetes Specialist Nurse
In this Communication Encounter, the main focus of the consultation is chronic disease management, and problems with adherence. Diabetes is the focus of this case. Other chronic illnesses may crop up in similar cases, such as COPD, asthma or epilepsy to name a few. The patient in this scenario feels she knows her own body and feels awful when she takes the full insulin dose every day. As part of exploring this further the candidate should ask about any hypoglycaemic episodes and how and how often she is testing her blood sugars. She also has problems with fear of weight gain. A good candidate should explain that there are numerous formulations of insulin, and most patients can find a regimen that suits them. However, this requires the patient to be committed to the general principle of controlling her blood sugar, to prevent future health problems which may be severe. Indeed, there’s evidence that she is also damaging her liver, and at this point the candidate should enquire regarding any alcohol intake that may also be contributing to this. The goal of the interaction here is not to convert the patient into a fully compliant patient by shocking her with the news of fatty liver disease, or by spending long periods of time talking about the severe complications of diabetes. The focus here is to make sure she understands the complications of poor sugar control. These abnormal liver tests are an indication these complications may follow very soon. You want to make sure that she is aware that running a high blood sugar long periods of time will only lead to detrimental effects to her health. You will not convert her in one consultation, and it is okay to admit that you don’t feel you’ve converted her ideas and beliefs.
Encouraging Insulin Compliance - keywords phrases.pdf
Encouraging Insulin Compliance - examiner instruction.pdf