No Provider Assessment??

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Specializes in Community Health, Med-Surg, Home Health.

Had a patient today who is an ex-con who just got out of prison a few months ago. Was a poly-substance abuser. Saw an order for a PPD. Doctor's note stated patient had chronic back pain, ordered Flexeril tid, Tylenol PRN (nothing else). Titers for Hep B and C are positive, but he is new to us, so, new bloods were ordered. Will be revisiting the clinic on one month after an abdominal sonogram (due to the Hep B and C) and CXR. Oh, and the provider is a resident, and all resident cases are reviewed by an attending in our clinic.

The patient refused the PPD, stating that he is no longer in jail living in closed quarters, and does not feel the need to have one. Spoke to him of the importance of why. Still refused. While asking the screening questions, patient stated he was diagnosed with Diabetes while in jail. Said he never took medications for it while incarcerated and he also said that he experienced hypoglycemia at least three times while in prison and described symptoms that sounded alot like peripheral neuropathy to me. He said he also has documents at home from prison that he can bring in to 'prove' his diagnosis. The resident is gone for the day, but I went to the attending that signed off and presented the information given to me by the patient and told her that I didn't see a note from the doctor stating that he was aware of this information.

The attending tells me that she doesn't believe that this patient has diabetes, because he would not have ever experienced hypoglycemia if he was not treated with any antidiabetic medications. I repeated what the patient shared with me and said that in spite of that, I think that he still needed to be evaluated for the possibility, especially if he is reporting that he is experiencing tingling and numbness of his extremities and the fact that he is claiming to have documented proof of his diagnosis. She started saying again how this can be something else, such as a tumor "or something". She checks the resident's note, sees that there was nothing documented (which it means to me that the man didn't ask his patient any questions, and also, that she, as the attending that signed off on the chart did not make sure that this student did actually assess properly). I said to her "Bottom line, what are we doing for this patient?" She does order a 2 hour post prandial glucose and A1c, but when I asked her if she would like to speak to the patient, she said "No, I am about to go home". I drew the A1c myself and instructed the patient on the importance of obtaining the other labs, abdominal sonogram and CXR. The patient still refused the PPD, but said to me "You were the only person who asked all of these questions and followed up. That man didn't ask me a thing...he just checked labs, made orders and that is all. At least someone cared." And, I rescheduled him for 3 weeks rather than a month so that he can be treated, if necessary, based on the labs and results of everything else.

My goodness, what are these medical students being taught?? The man was certainly open enough to share, and if I can come across this information with the screening that the nurse does, how is it that all of this information was missed??:banghead:

Also, this may be a dumb question, but am I correct in thinking that just because this man was not treated for diabetes, even with oral medications, that he may still experience symptoms of hypoglycemia?

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Specializes in Cardiac Telemetry, ED.

Good for you! I don't see why it would be the skin off the doc's nose just to order an A1C. Sheesh.

Also, this may be a dumb question, but am I correct in thinking that just because this man was not treated for diabetes, even with oral medications, that he may still experience symptoms of hypoglycemia?

I don't think so. Hypoglycemia in diabetes is a result of too much insulin/medication and not enough food/too much physical activity.

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Specializes in Ortho, Case Management, blabla.
Good for you! I don't see why it would be the skin off the doc's nose just to order an A1C. Sheesh.

I don't think so. Hypoglycemia in diabetes is a result of too much insulin/medication and not enough food/too much physical activity.

I agree with this. One of my favorite things about working the med-surg floor are some of the people that are diabetic. I've had people argue with me and say, "I NEED FOOD NOW, IM A DIABETIC. I NEED MY DIABETIC SNACK", this when they're 1 hour postop with general anesthesthia and I've been trying to get them to stick to ice chips because they've been N/V. I chuckle because food is probably the last thing they need when their fingerstick is still 150 in spite of the fact that they haven't eaten in 24 hours. Yea, eat a snack...

Also, another thing, my cousin has chronic hypoglycemia and it is like the opposite of diabetes. She is 5'8", weighs 100lbs, has no body fat whatsoever, and no matter how much she eats she doesn't really gain any weight. She has to eat a lot of snacks to keep her sugar up or else she gets light headed and passes out.

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Specializes in Community Health, Med-Surg, Home Health.

I felt the same way-we don't know what sort of activities this man participated in while in jail. He could have been a gym buff, constantly working out, fighting, so many reasons for his glucose levels to drop. I think that this doctor was trying to brush me off because she was embarassed that both, she and her resident did not do a proper assessment.

I was concerned, because I told the patient that if he is diabetic, then, the entire treatment plan would have to change, especially if he was a polysubstance abuser! He also used to abuse alcohol. He was open enough to sit and listen to my teachings and rationale, so, let's give this man a chance to know the full scope of his health to make educated decisions on his care. He probably won't comply, but at least he'll be aware of his choices.

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Specializes in Community Health, Med-Surg, Home Health.
Good for you! I don't see why it would be the skin off the doc's nose just to order an A1C. Sheesh.

I don't think so. Hypoglycemia in diabetes is a result of too much insulin/medication and not enough food/too much physical activity.

I think I saw in another thread that you were going for your pinning ceremony. How was it? And congrats!:yeah:

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Specializes in Community Health, Med-Surg, Home Health.

I don't think so. Hypoglycemia in diabetes is a result of too much insulin/medication and not enough food/too much physical activity.

I just thought of something else-he told me he used to make bootleg alcohol while in prison. Many of them do not eat well, which would be another reason to become hypoglycemic. Thanks again for the clarity. I didn't think I was nuts.

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Specializes in Hospital Education Coordinator.

yes you can have hypoglycemia without being diabetic. It is sometimes a form of pre-diabetes. And there are lots of things that affect our metabolism besides insulin. Could be he has a pancreas that produces too much or a liver (more likely) that is sick. At any rate, you did the right thing by following up on your instincts!!

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Specializes in Cardiac Telemetry, ED.
I think I saw in another thread that you were going for your pinning ceremony. How was it? And congrats!:yeah:

It was awesome! Not a dry eye in the place! Thank you!

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Specializes in Community Health, Med-Surg, Home Health.
yes you can have hypoglycemia without being diabetic. it is sometimes a form of pre-diabetes. and there are lots of things that affect our metabolism besides insulin. could be he has a pancreas that produces too much or a liver (more likely) that is sick. at any rate, you did the right thing by following up on your instincts!!

yes, i know that a non-diabetic can experience hypoglycemia (on rare occasions, this happens to me-and i'm not diabetic); what i was questioning was the doctor's rationale: she is saying that there is no way he can be diabetic, have no treatment with antidiabetic medications and experience hypoglycemia. i felt that she was wrong. i believe that there are many reasons for this to happen to a prisoner who is making bootleg alcohol, probably either fighting or exercising, and bad eating habits. i can understand that there are other reasons for the low glucose, but she was trying to blow me off because she was embarassed, i believe.

this is supposed to be a teaching hospital, and i believe that this was an opportunity to get together with this resident and review his assessment skills. i'm not looking for him to be creamed across the carpet, but i can see that he really ignored his patient and did not inquire far into his history. like you, i suspect that due to the alcoholism, hep b and c, his liver is not in the greatest condition.

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Specializes in Maternal - Child Health.

pagandeva,

I agree that it is possible for an unmedicated diabetic to become hypoglycemic. One of the aspects of Type II diabetes is that the pancreas may respond erratically to glucose consumption. On one occasion, the pancreas may secrete too little insulin to compensate for glucose intake, resulting in hyperglycemia. On another occasion, it may oversecrete, releasing too much insulin for the glucose consumed, resulting in a hypoglycemic episode.

Thank you for being so conscientious with this man :)

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Specializes in Community Health, Med-Surg, Home Health.

I thought so, as well, and you worded what I was trying to work out in my mind. Thanks a bunch, everyone!

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You're a great nurse, pd.

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