Background: About This PBL Case
This case is intended to provide an interprofessional team of learners with an opportunity to collaborate and determine their patient’s needs. The patient is a 65-year-old man with poorly controlled diabetes, a recent foot ulcer, dietary insufficiencies, social concerns, and sequelae of diabetes mellitus. He presents after requiring work disability insurance related to the foot ulcer, revealing his complex condition. He also has compounding social issues, including insufficient and insecure finances, alcohol dependence, and a dysfunctional relationship with his estranged children. He has been divorced for seven years. The group will need to navigate their way through monthly clinic visits. A new segment of the case will be revealed in each session, and students will be encouraged to collaborate, creating an interprofessional action plan that is effectively tailored for this patient. The participating students are responsible for their own learning while contributing to collective learning as a group. Some research between meetings is expected with information brought back to the group to help progress work in the subsequent session.
This case is geared towards students from the following health professions disciplines:
- Medical students (2nd year)
- Nursing students (2nd year)
- Nutrition students (3rd year)
- Pharmacy students (3rd year)
- Physiotherapy students (2nd year)
Mr. Sucre is a fictional character. This case was created for educational purposes.
Mr. Sucre is a 65-year-old from Watrous, Saskatchewan. Mr. Sucre presents himself to a new physician with a sore on the bottom of his right foot. He works as a labourer but has recently had to go on disability due to his foot ulcer. Mr. Sucre requires the physician to complete paperwork for the disability agency. In reviewing Mr. Sucre’s past medical history, you learn that he has been diagnosed with type 2 diabetes, compromised renal function, hypertension, and ’some difficulty controlling his alcohol intake’. The client appears unkept with a flat affect. Mr. Sucre reports he was started on “diabetic pills” about two years ago but did not take them regularly because of the “side effects”. The client reports he does not eat very well because he cannot afford groceries and has trouble making it to the grocery store due to his work hours. Mr. Sucre currently receives meagre social assistance on top of his minimum wage. The client lives alone and has two grown children with whom he does not interact. Mr. Sucre has two drinking friends whom he sees a few times a week. The client indicates that he enjoyed watching local hockey games but has not wanted to go to the games this season. Mr. Sauce is advised that he will be started on insulin for better glycemic control, which is crucial to retard the development of further complications and heal the foot ulcer.
The group’s role is to determine what type of initial investigations and resources Mr. Sucre needs. What types of consultations will you make? You will meet Mr. Sucre in one month for a follow-up.
- What are the predominant types of diabetes, and what are the risk factors? What is a multifactorial disorder? What is the web of causation?
- How do biological, psychological, and social factors interact in the development of diabetes and its complications? Do finances play a role?
- What is hyperglycemia, and what are the implications of prolonged hyperglycemia in diabetic patients?
- What is hypoglycemia, and why is it a problem in diabetes?
- What are the acute life-threatening emergencies associated with uncontrolled diabetes?
- What are some long-term complications?
- Which systems and organs are most affected by poorly controlled diabetes?
- How does alcohol interact with diabetes?
- What could be the “side effects” of oral diabetes medications, and more importantly, why is Mr. Sucre not addressing these concerns with his care providers? How does a patient’s perception and lack of knowledge contribute towards worsening the situation?
- Why are patients more prone to develop diabetes as they age?
- How does inactivity increase the risk of diabetes?
- How does inactivity contribute to the development of diabetes complications?
- Describe the nutritional changes that diabetic patients might need to make?
- What food groups are likely to be missed when purchasing meals at a convenience store and why?
- What resources could be utilized to improve a client’s diet?
- What are the financial implications of being off work due to a foot ulcer?
- What are the potential mental health implications of chronic diseases and isolation?
- What effect do uncontrolled blood glucose levels have on the integrity of feet, kidneys, and vision?
- What precautions should be taken while consuming insulin therapy?
- What resources are available should the client start insulin therapy?
- How do diabetes education programs and physician appointment times become more accessible/convenient for clients?
- How would you summarize Mr. Sucre‘s case based on what you currently know?
- As a collective group, what are your top 3-4 priorities?
- What other health professions need to be at the table to provide care to Mr. Sucre?
- What other questions would you have for Mr. Sucre regarding his personal life and medical history?
- Can you name some situations that make diabetic control more difficult?
- How does the laboratory value of HbA1c reflect diabetic control?
- What are the implications of poor foot care in a patient with diabetes?
- What are the effects of diabetes on vision?
- Common complications of diabetic patients are cataracts, kidney dysfunction and neuropathy. Why does this happen, and how can it be prevented?
- What types of resources could be utilized to increase medication compliance and consistent blood glucose monitoring?
- What medication may be needed for the infection? What are some potential complications in starting these?
- How do you educate clients on cooking skills?
- What access would the client have to community resources that assist with acquiring more fresh food at a reasonable price (e.g., community gardens)?
- Why might patients not access or follow up with medical services?
- What access do rural clients have to internet and cell phone services? How might this impact access to resources and services?
- What types of free online educational resources would be available to the client (e.g., Diabetes website Canada needs a nation-wide diabetes strategy now – Diabetes Canada).
- What type of recreational physical activities would be available to the client?
- What are some considerations for footwear for patients with diabetes? How can we teach/educate diabetic patients to take care of their feet themselves?
- What resources could be used to take care of the foot ulcer with adequate wound cleaning and dressing frequency? What is the role of home care nurses?
- What type of microbes involves the diabetic feet, and how does impaired immunity in people with diabetes make the condition worse?
- How bad does a diabetic foot ulcer get? Can the foot infection be an indication for leg amputation in people with diabetes? Do people with diabetes have trouble keeping a balance in their foot and ankle joints (Charcot joints)?
- How do we prioritize the interventions for the client?
- What other community resources can our client access in his rural setting?
- How would you assist Mr. Sucre with medical compliance and adherence to lifestyle changes?
- What social support systems are in place in his community?
- What effects does social isolation have on health?
- What mental health services may be needed for Mr. Sucre?
- How do you approach mental health concerns with patients?
- How does financial insecurity contribute to health status, including poor glycemic control, cardiovascular diseases, and psychological well-being?
- What support programs are available for individuals who are facing a financial crisis?
- What are some implications of homelessness for a person with chronic disease conditions?
- What assistance can home care provide with housekeeping services for those unable to afford private cleaning services?
- If a client’s kidney functions continue to decline, what resources for dialysis treatments are available in a rural setting?
- What acute changes may lead you to consider admitting Mr. Sucre to the hospital?
- What gradual/chronic changes may lead you to consider admitting Mr. Sucre to the hospital?
- What further consultation is required for diabetic neuropathy and vasculopathy? (ie. microvascular and macrovascular)
- What determinants of health are most important to address in Mr. Sucre’s case?
- How does living in rural Saskatchewan impact people with chronic diseases? How can we mitigate these impacts?
- What other medical and social considerations would you want to monitor going forward for Mr. Sucre?
- What considerations should be made regarding community-based management versus hospital-based management for Mr. Sucre?
Mr. Sucre is a fictional character. This case was created for educational purposes.