Background: About This PBL Case
This is a fictitious case to encourage interprofessional collaboration between health profession students. This case is designed for third year medical students, third year dental hygiene students and third year veterinary medicine students.
Students will be able to:
- Identify common symptoms associated with diabetes mellitus and its acute complications and note comparisons between people and dogs
- Analyze the history and report a possible uncommon complication of diabetes mellitus
- Assess the importance of patient education and provide necessary recommendations regarding diabetes mellitus
- Describe the barriers to treatment for a diabetic patient
Mrs. Candy is a 70 year-old woman with Type 2 diabetes and diabetic retinopathy. She lives with her husband and her dog.
Mrs. Candy was found by her neighbor around 1 pm, distressed and diaphoretic, in the front yard after her dog was barking uncontrollably. Mrs. Candy told her neighbor that she recently took her insulin dose as scheduled at 1pm, however, she has been feeling unwell since then. Mrs. Candy shows her neighbor the insulin syringe that she used which was a U-40 syringe. The neighbor then called 911 and Mrs. Candy was taken to the Emergency Department via EMS.
Mrs. Candy is assessed by a 3rd year medical student, who has been sent on behalf of their ER physician preceptor. The only information provided so far is her random glucose is 20 mmol/L and she has bleeding gums, but no other bleeding manifestations.
- Explain the warning signs for a patient’s well being in an emergency room?
- What are the differential diagnosis (include problem list and corresponding differential diagnoses)?
- Why should we be checking the patient’s medication at the time of examination?
- What kind of insulin and insulin syringe is commonly used in your species (i.e humans vs. dogs)?
- What is the significance of the U-40 syringe?
- What bedside investigations can you do for this patient?
- Explain the acute complications of Diabetes Mellitus.
- How can you differentiate between Hypoglycemia, Diabetic ketoacidosis and Hyperosmolar non-ketotic coma/hyperglycemic hyperosmolar syndrome?
- What are important history questions to ask the patient/client or bystanders?
- Why is it important to ask the patient about their last dentist/dental hygiene visit?
- What information can be gathered by the pain in the patient’s mouth?
- Explain the importance of informing the patient that everything in their body is connected and therefore by neglecting one area, she is negatively influencing other areas as well.
- What do we need to know about the bleeding gums to solve this problem?
- How is the patient’s response of how often she brushes and flosses her teeth relevant to the issue at hand?
- What are you assuming when you bring up periodontal gum probing to your patient?
- Describe the common insulin doses/insulin types in various humans and dogs and how do we classify them?
- With the information gathered today, what would your next step for Mrs. Candy be?
- What safety concerns have been highlighted in the case so far?
Collateral history is provided from her husband who showed up later to ER, once informed of Mrs. Candy’s condition by her neighbor. He tells you that they have been together for over 40 years. Mr. Candy does report his wife has been confused with medications over the past few weeks to months. She has also been missing her dental appointments and she has a toothache in the left upper mouth area, recently with bleeding gums. She has also been missing a few medical appointments. Their dog is also a diabetic and the husband is worried that she may have accidentally injected herself with the dog’s insulin as opposed to her own short-acting insulin. Aside from her difficulties with her memory, she is very independent of all her activities of daily living.
Abdominal Examination: Soft non tender, not distended, bowel sounds present, no masses
Cardiovascular Examination: Normal S1S2, nil murmurs, HR regular
Neurological Examination: CN (cranial nerves) II-XII grossly intact
Respiratory System Examination: Air entry equal bilaterally, no adventitious sounds
HEENT – tenderness and swelling left upper molar area
Dental Periapical X-ray of quad 2 molars: Findings-Subgingival calculus spurs.
Random Blood sugar: 20 mmol/L
Renal Panel – Na 130 meq/L, K 3.5meq/L, Cl 98 meq/L, Cr 0.8 mmol/L, eGFR 90mmol/L
Ketonometer – 0.2 ( RR <0.6 mmol/L)
CBC – White cell count 11, Hb 137, Plt 375
HbA1c – 8.9
BP – 130/87
HR – 74 bpm
RR – 12 brpm
SP02 – 98%
Temp – 37C
**The only abnormal labs are White cell count, random blood glucose and HbA1c, remaining above labs are within normal
**DKA workup is negative
- What is the importance of checking vitals in an ER?
- Why is it important to ask the patient if she is interested in keeping her teeth long-term?
- Based on your knowledge of the patient, why do you believe she needs help accessing her gum deep pockets?
- Why is it important to ask the patient if she can commit to the 3-4 dental hygienist cleanings it may take to have her teeth cleaned?
- Why is collateral history important?
- Why do we need to see the medications in the ER?
- What is a glucometer? How does it work?
- How can you differentiate between hypoglycemia and hyperglycemia?
- What are tests that assess a patient’s diabetic control over a longer period and how do those relate/differ in humans/dogs?
- What are the steps you should take if a human takes dog insulin?
- There are long term complications to diabetes, especially if it is uncontrolled. How are these similar/different in people/dogs?
- What are strategies you could recommend to your client/patient who may be having difficulties with insulin administration for their pet (for themself?) or may be mixing up medication?
- How does this patient’s oral health and overall diabetic control affect each other?
- Summarize the factors that may be contributing to Mrs. Candy’s uncontrolled diabetes mellitus.
Mrs. Candy is stabilized in the emergency department and is ready for discharge. The healthcare team advises several follow ups:
- What healthcare members should be involved in Mrs. Candy’s discharge/follow-up plan?
- How would you teach Mrs. Candy to brush and floss her teeth daily?
- Why do you think dental cleanings every three months is a good idea for her?
- What are important parts of client education for type two diabetes (regardless of the species- human, animal etc)?
- How would you teach this patient about insulin injections?
- How can we work with the patient to improve her HbA1c?
- What social determinants of health could be affecting Mrs. Candy?
- What follow up care does the dog need in case of inappropriate insulin administration?
- What is the most important thing you took from this case?
- How can you apply the information you learned from this case to your future clinical practice?