GENERAL PRACTICE

CASE STUDY 2020

TITLE: A DEEPER UNDERSTANDING OF TYPE-1 DIABETES MELLITUS

STUDENT ID: 18100753
WORD COUNT: 2401 WORDS

Declaration: I hereby declare this work to be my own. Any published or unpublished

information contained within has been referenced in the requested manner. I sought and
received this real patient’s consent to write this report. The name of the patient and any
countries/places have been changed for the purpose of my case report to ensure total patient
confidentiality.
 I. INTRODUCTION

The Health Service Executive describes Primary Care as a health or social care service that
one can find in his own community, outside of hospitals, ranging from the General
Practitioner Service and Practice Nurse Service to Physiotherapy and Social Work Service
[1,3]. Since the announcement of the Primary Care Strategy in 2001, a great deal of Primary
Care Centers was implemented throughout Ireland [2]. I enjoyed my time in Clinic X and
was fortunate enough to be showered with a plethora of knowledge and experience by Dr X
for 2 weeks albeit feeling it was a little short-lived.

“Type 1 Diabetes is a completely manageable disease. But, there are some days
that are just rough. Just know that you are not alone.” – Nick Jonas

This case report will discuss about Mrs Q, a Y-year old Irish lady, who is battling
complications of Type-1 Diabetes Mellitus (T1DM) in pursuit of a decent quality of life. She
had been diagnosed with T1DM 20 years ago and had to bear and suffer from inadequate care
by incompetent and unprofessional consultants in the past before experiencing the positive
by-product of a metamorphic improvement in healthcare in Ireland during the later course of
her illness. Mrs Q deluged me with plenty of information and expressed a multitude of
emotions describing her point of view on T1DM.

II. PATIENT’S VIEWPOINT

As advised by my GP tutor X, I went through Mrs Q’s charts through the computer a few
days prior, focusing on all referral letters, investigations, medications, and GP notes from
previous consultations. From the files, I understood that the ‘tag’ T1DM does not just end
there, but it also came with its complications – peripheral neuropathy, disturbed quality of
life, emotional stress – all of which Mrs Q had experienced ever since the start of her illness.
Apart from the struggle she has with the T1DM scene, she had to face recurrent infections
from psoriasis all over her body.

Being the over excessively nervous medical student that I am, I mustered up the courage to
begin my task and escorted Mrs Q from the waiting area into the room when I noticed a
subtle limp on her right leg to which she explained the sensation on her feet to be “a sharp
pain, but it is as if it is burning, but numb too, if that makes sense. It would go very cold. It is
really strange”. This pain started in 2018 and it hinders her from walking far distances as she
would have normally been able to a few years ago. She used to be able to exercise regularly,
but she is incapable to do so now because of the extreme pain. She stated that T1DM and its
complications are all a part of “a harmful cycle” that affected and “ruined” her whole life.
She was stressing about how she is unable to exercise efficiently – one of the best lifestyle
methods that can help her disease to progress slower. Knowing that Mrs Q walks almost 30
minutes to and from her workplace, I cannot begin to fathom the kind of pain she experiences
daily. When asked about how she copes with it, she responded that it was necessary for her to
earn a living to support her family. “I got very down, and I thought I could not cope anymore.
It’s so bad, but I cannot bear it if my family has nothing to eat”.

The pain on her feet impacted her not just physically, but socially too. She would decline
invitations to go out for drinks with her friends because she is incapable of standing or
walking for long hours. Besides that, Mrs Q feels somewhat humiliated when she must
excuse herself to the toilet so that she can get that little privacy to inject insulin into her
abdomen. Over the past year, her friends secluded her from outings and parties. Mrs Q
believes the reason that happens is that she had declined invitations numerous times in the
past to the extent by which her friends saw no reason to invite her anymore. Now, after
realising how common T1DM is, Mrs Q does not bother hiding her need for medications
from her friends. She mentions openly the need to take insulin and excuses herself. There is a
clear reorientation of her mindset regarding T1DM after 2 decades of education.

Mrs Q was diagnosed with T1DM during her pregnancy at 20 weeks. She was given insulin
during her pregnancy and was subsequently switched to a tablet medication for 6 weeks with
an impression that it would resolve. She ate the medication religiously but when she went for
follow-up, the doctors told her she was not improving and diagnosed her with T1DM.

“That was it. I’m stuck with this burden. For life.”

I will never forget these ten powerful words muttered by Mrs Q as it shows how devastating
to life and shocking it is when one is diagnosed with a chronic illness. This was when I
realised she was not just my assignment, but she is a human being, with a life worth living,
just like any one of us.
Mrs Q was then discharged for outpatients’ review and was seen under a consultant K. She
was petrified by the thought of having to go for follow-ups because she felt intimidated when
Dr K would interpret her blood glucose readings in front of her, criticize every aspect of her
lifestyle and comment on how everything she does to manage her diabetes was ‘a mistake’.

“If you had Diabetes, and a doctor tells you off, you would cry because it is stressful – and I
did”.

She was also not offered and educated about the DAFNE program up until a few years ago
and felt disappointed in the Irish healthcare system. Mrs Q had to learn how to ‘carb count’
all by herself from the extensive research she did online.

However, prior to self-education on self-management techniques, I felt as if Mrs Q was

thrown into a dark corner. She did not balance carbohydrate intake and insulin shots well
which resulted in four hypoglycaemic unawareness a day in the later stages of her illness. At
the time, she was not aware that there was such a thing as hypo-unawareness so she panicked
every time she sees a high blood glucose reading as she is afraid it might ‘damage’ her,
causing her to either inject more insulin or eat less carbohydrates.

Having both T1DM and psoriasis pose a great deal of stress psychologically to Mrs Q
because with these illnesses comes the responsibility of medication compliance. She thinks it
is hard to “juggle too many things” on her mind. She complains about having missed insulin
shots rarely because she is just too tired to fetch the pen and to inject it. However, she would
miss out on her Betacap and Penicillin treatment for her psoriasis often because she thinks it
is not as severe as her diabetes.

“I love my daughter and my family and will fight for them by eating and trying my best to
exercise well. Doing that, I think I will be grand, and I will not let diabetes take me.”

The quote above by Mrs Q speaks volume about her resilience living with T1DM. She talks a
lot about her Y-year-old daughter living with her. I could sense a hint of vulnerability deep
down when she starts blaming herself for the heart malformation her daughter has. Her
explanation of how her maternal diabetes caused the defects in her daughter’s heart
accompanied by her shaky voice and teary eyes speaks a lot about how T1DM can impact
someone psychologically.

I was fortunate enough to have a quick interview with HQ, Mrs Q’s daughter. She describes
Mrs Q as a strong, loving mother who tries very hard to give the best for her family. She
mentions that it might be a little tough sometimes as she must occasionally help clean her
mother’s feet to prevent any feet infection. She would occasionally remind her mother to take
insulin jabs during a meal. HQ never forgets to keep with her some sugary sweets and drinks
every time they go out together, because she is “worried mom might collapse”. HQ studies in
NUI Galway and on some days, she feels worried if her mother does not reply her texts as she
is worried about hypoglycaemia, even though “she is probably taking a nap”. Nevertheless,
she states that caring for her mother is a responsibility that one should cherish.
 III. GENERAL PRACTITIONER’S VIEWPOINT

It was apparent from the beginning that Mrs Q and Dr X shared a close and unique patient-
doctor relationship that I had never seen before. Mrs Q puts all her faith in Dr X because she
states that Dr X is the first doctor to establish a “respectful, professional, warm and cozy”
rapport with her. Their almost telepathic doctor-patient rapport is unreal, and it is something I
will take as an exemplar when molding myself as a doctor.

My GP describes Mrs Q as a patient who was treated unjustifiably when she was first
diagnosed with T1DM. She expressed admiration towards Mrs Q for showing trust in the
Irish healthcare system after seeing such a rude doctor rebuking her actions. Dr X acts as a
personal confidant to Mrs Q much like how Tom Hagen was consigliere to the Corleone
family in The Godfather. Dr X would counsel Mrs Q on healthy lifestyles at each
consultation just like how Consultant K would, except that she did not do it in a
condescending or rude tone. Dr X would comfort Mrs Q about the issue regarding her
daughter’s heart defect – in that it is not her fault and her daughter is very well managed
while living an excellent quality of life.

One of the struggles my doctor faced was that she hoped she could get more than 15 minutes
of consultation with Mrs Q. She felt that Mrs Q deserves more time to establish an even
closer rapport than what they already have. Also, Dr X informed me that it was quite a
struggle getting Mrs Q to change her habits about diet and exercise at the start. All these
problems stem from the inappropriate consultation she received during the earliest stage of
her illness.

Another struggle my tutor faced throughout her history with Mrs Q revolves around the fact
that she is unable to properly classify Mrs Q under a class of Diabetes Mellitus. She called it
“Diabetes Type-1.5” – more formally known as Latent Autoimmune Diabetes in Adults
(LADA). To classify her correctly, many predicaments must be answered - Is LADA
different pathophysiologically from classic childhood type 1 diabetes or is LADA merely
type 1 diabetes presenting at an older age [4]? Would that have an impact in the management
of Mrs Q? If her insulin therapy is working, would we emphasize on finding out the nitty-
gritty details within a grey area? Dr X struggles with the debate of T1DM and LADA herself,
but strives to ensure that regardless of the essentials of the problem, Mrs Q must be properly
managed and excellent quality primary care must be given.

I believe that the management plan formulated by my tutor is a logical plan that follows the
plan NICE guidelines has set in place for doctors – stressing on dietary management, physical
activity, blood glucose management and insulin therapy [6]. I felt relieved when I heard that
Mrs Q was prescribed Neurontin, which successfully alleviated some of her pain in her feet.
A suggestion that I would make in terms of managing Mrs Q would be a fundoscopy to
screen for retinopathy. According to the Framework for the Development of a Diabetic
Retinopathy Screening Program for Ireland, as much as 6 % of patients are prevented from
blindness within one year of treatment, and 34% within 10 years of treatment [5]. Despite not
having any complaints about her vision, I am certain that checking for all microvascular and
macrovascular complications of diabetes is empirical to ensure a good outcome and to catch
any progression of the disease early.
 IV. STUDENT’S PERSPECTIVE

When I first read about this assignment on Blackboard, there were 3 things that kept popping
up in my mind – marks, marks and marks. 30% allocated to a case study was mind-blowing
to me, so much so that I ended up preparing my lining of questions since the first day of my
GP rotation. I thoroughly cross-examined and autopsied the marking rubrics in hopes that I
could salvage every mark salvageable.

Being absolutely honest, I had that – disgusting – mindset for almost 10 minutes out of the
60-minute interview with Mrs Q. The only thing that was going on in my mind at the time
was that she was very long winded because I wanted to end the interview fast. However,
everything changed from the moment she started getting weepy talking about her daughter. I
then realised that I was dealing with human emotions. I finally understood what messages the
lectures I had was conveying – a good doctor can diagnose and cure diseases with a snap of a
finger, but a great doctor can do what a good doctor can plus being an excellent comforter to
the sick.

Meeting Mrs Q in the clinic is a refreshing experience as it is very different from meeting a
diabetic patient in the ward. She appears very well managed and has very few diabetic
complications.

One thing I learnt from my experience with Mrs Q is that I should show more interest in
patients regardless of their stories. It is the only true way to build rapport. When a patient
recognises that her doctor is showing interest in her history, she would be keener and less
reluctant to share intimate details – and none of this could be achieved without a foundation
of trust.

Besides that, I learnt that apart from the physical management of T1DM, or any disease for
that matter, psychological and social management plays a pivotal role in ensuring an efficient
patient-centered care. This will allow for a better prognosis and quality of life which is what
patients ultimately want.
To conclude, I will strive to incorporate what I have learnt from Mrs Q into shaping my
future as a doctor. I will show empathy, interest and be compassionate whenever I consult a
patient. After all, they are all just humans like me.

Figure 1 Patient Centered Care [7]

 V. BIBLIOGRAPHY

1. Research in Primary Care - HSE.ie [Internet]. HSE.ie. 2020 [cited 28 January

2020]. Available from:
https://www.hse.ie/eng/services/list/2/primarycare/research.html

2. Mercille J. The Public–Private Mix in Primary Care Development: The Case

of Ireland. International Journal of Health Services. 2019;49(3):412-430.

3. Gov.ie - Primary Care – A New Direction [Internet]. Gov.ie. 2020 [cited 28

January 2020]. Available from: https://www.gov.ie/en/publication/a15f22-
primary-care-a-new-direction/?referrer=/blog/publications/primary-care-a-
new-direction/

4. Palmer J, Hampe C, Chiu H, Goel A, Brooks-Worrell B. Is Latent

Autoimmune Diabetes in Adults Distinct From Type 1 Diabetes or Just Type 1
Diabetes at an Older Age?. Diabetes. 2005;54(Supplement 2):S62-S67.

5. [Internet]. Diabetes.ie. 2020 [cited 28 January 2020]. Available from:

https://www.diabetes.ie/wp-
content/uploads/2014/11/Framework_for_a_Diabetic_Retinopathy_Screening
_Programme_1.pdf

6. Poole R. Type 1 diabetes in adults: new NICE guidance on diagnosis and

management. Practical Diabetes. 2015;32(8):279-280.

7. What Is Patient-Centered Care? [Internet]. Catalyst.nejm.org. 2020 [cited 28

January 2020]. Available from:
https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559