NDEP | National Diabetes Education Program

Hypothetical Case Examples

A 70-year-old woman with diabetes tells her eye care provider that her blurred vision is such a problem that she is afraid to cut her toenails.
She states “They are so long, my shoes don’t fit!” She has worn oversized bedroom slippers to the appointment. The eye care provider asks the patient to take off her slippers, and finds overgrown, thickened toenails that have curled around and are cutting the skin. The woman has little sensation and has noticed no pain though several areas are red. The eye care provider arranges for the patient to be seen that day by her primary care provider or a podiatrist for foot care and emphasizes the importance of prompt treatment to avoid serious injury.

A dental hygienist notes that her patient smokes. She tells him that smoking can cause oral cancer and she describes the impact tobacco use can have on increasing diabetes complications. She asks the patient to consider quitting as an important step in controlling his diabetes and gives him the 1-800-QUITNOW number.

A 40-year-old woman asks her local pharmacist for advice on reading glasses. She says, “I must be getting older, everything is just blurry.” The pharmacist uncovers a history of diabetes, diagnosed the previous year, but discovers that the patient never returned for follow-up. The pharmacist advises the woman that her blurred vision may not be a need for reading glasses but in fact a sign of diabetes and arranges for the woman to be seen by a primary care provider and eye care provider for follow-up.

A podiatrist notices his 35-year-old patient with diabetes has terrible breath and asks about it. The patient is embarrassed but admits that he has noticed a bad taste as well. A quick look in the patient’s mouth reveals inflamed, swollen gums with pus at the gum line. The podiatrist describes the link between periodontal disease and poor blood glucose control and stresses the need for urgent dental attention for a possible abscess.
The podiatrist’s office helps the patient obtain a same-day dental appointment for care.

A dentist needs to schedule a patient for several procedures and asks about the timing of the patient’s morning insulin. The patient is confused about his complicated medication regimen and asks, “Should I just skip all medicines that day until after you work on my teeth?” The dentist phones the patient’s pharmacist to arrange a consultation. The pharmacist collaborates with the primary care clinician to develop an individualized medication schedule and advises the patient and his dentist on whether to hold medications the day of the procedure.

A man with diabetes of more than 20 years duration, and neuropathy, asks the pharmacist for an Ace wrap and advice on care of his foot, which is warm, red, and swollen. The man recalls no trauma and there is no evidence of skin breakdown or an open wound. The pharmacist arranges for a same-day referral to a podiatrist for possible cellulitis. Upon physical exam and X ray of the affected foot, the podiatrist diagnoses Charcot arthropathy and implements a plan of treatment with no weight bearing and close follow-up, with casting, until the edema resolves.

Where can I ever find the time?

How realistic is it for a busy optometrist to look at a patient’s feet?
Or any of the scenarios described above? You have limited time
to provide patient care. But research has shown that health messages direct from the provider, e.g., “I recommend that you…” are more effective than generalizations or third-person recommendations such as “You should see someone about that…” or “The American Diabetes Association says that…”

You don’t need to be an expert or do a thorough exam to identify that a problem needs attention by a specialist. It takes less than a minute to look at a person’s foot, mouth, or eye, or to ask a few questions about medications, supplies, or tobacco use. You reinforce the importance of preventive care if you take time to check a complaint yourself before recommending referral to another provider. Support comprehensive diabetes care: think beyond your own discipline to identify other potential problems. Then refer with an “I recommend…” message. Patients will appreciate your concern for their health and well-being as a whole. Establishing a referral system with other providers can improve your patient’s health and increase your referral base as well.

May 2007