Diabetes Review OSCE - Poorly Controlled Type 2 Diabetes

Case Overview

• Age/Sex: 56-year-old male
• Occupation: Office administrator (sedentary job)
• Setting: Primary care / diabetes clinic
• Chief complaint: "Diabetes check-up"

Patient Script

Who I Am

I'm 56, work behind a desk in an office, and I smoke about a packet every two days.

What Brings Me In

I was told it was time for my diabetes check-up — I feel more thirsty lately and I'm worried my sugar is getting worse.

My Story

I was diagnosed with type 2 diabetes about 8 years ago. For most of that time I was told my sugars were "a bit high" but okay. Over the last 6 months I've noticed I'm thirstier than before and I get up 2–3 times at night to pee. I often feel a bit tired in the afternoons and sometimes my feet tingle at night — that's been going on for a few months. I haven't lost or gained much weight; my clothes fit about the same.

I usually take my tablets but I sometimes skip the sulfonylurea when I forget or if I'm eating out. I haven't started insulin and I haven't seen the diabetes nurse for about 9 months. I try to eat less sugar but I do have biscuits at work most days. I haven't been very active — my job is desk-based and I don't exercise regularly.

A few other things: I had a bad chesty cough after a cold last month but it cleared up. I also get the occasional swollen ankle after long flights or if I sit for ages — it goes down after a day. I started taking an over-the-counter herbal tonic for energy a few weeks ago (I think it's ginseng).

My Medical Background

• Past medical history: type 2 diabetes (8 years), diagnosed hypertension 6 years ago
• Medications: metformin 1 g twice daily, gliclazide 80 mg mornings, lisinopril 10 mg once daily, atorvastatin 20 mg nightly
• Allergies: none known
• Social: smokes ~10 cigarettes/day (about 20 pack-years), drinks alcohol socially (~8–12 units/week), sedentary job, lives with spouse
• Family: father had a heart attack at 67, mother has type 2 diabetes

What I Think & Worry About

• I think my sugar might be getting worse because I feel thirstier and tired.
• I'm worried I might have to go on insulin and I'm scared of injections.
• I worry that if my sugar gets worse I might lose my job or not be able to drive long distances.

If You Ask Me About Other Symptoms...

• Thirst / urine: "Yes, I'm drinking more and getting up to pee 2–3 times at night — that's new over the last 6 months."
• Weight: "About the same as this time last year — I haven't really lost weight."
• Vision: "Sometimes things look a bit blurry, especially when I'm tired, but it comes and goes."
• Feet: "My toes tingle at night and I have less feeling sometimes, but no open sores."
• Chest: "I had a cough last month but it went away. I do get a bit breathless if I hurry up the stairs, but no crushing chest pain."
• Sexual function: "I have noticed it's harder to get or keep an erection recently."
• Medication adherence: "I take my metformin most days; I sometimes skip the other tablet when I'm out or forget."
• Recent illnesses or steroids: "No steroids, just that cough a month ago and I took some cough syrup."

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Clinical Summary

Examination

• General: overweight man, comfortable at rest
• Vitals: T 36.7 °C, HR 88 bpm, BP 150/92 mmHg, RR 16/min, SpO2 97% on air
• BMI: 32 kg/m2, waist circumference 110 cm
• Cardiovascular: normal S1/S2, no murmurs, peripheral pulses present and symmetrical
• Respiratory: chest clear
• Abdomen: soft, non-tender
• Neurological / peripheral neuropathy: reduced light touch to 10 g monofilament on both feet (loss in stocking distribution), reduced vibration at the great toe, ankle reflexes diminished
• Lower limbs: no foot ulcers, no calf tenderness, mild dependent ankle pitting oedema after prolonged standing
• Eyes: patient reports intermittent blurring; fundoscopy in clinic: background (non-proliferative) diabetic retinopathy changes (microaneurysms/dot-blot haemorrhages) reported

Investigations

• Random capillary glucose: 15.0 mmol/L (270 mg/dL) (elevated)
• HbA1c: 10.2% (88 mmol/mol) (poor glycemic control)
• Fasting plasma glucose (if available): 11.5 mmol/L (elevated)
• Urine albumin (24 h): 120 mg/day (microalbuminuria)
• Serum creatinine: 95 µmol/L (eGFR 68 mL/min/1.73 m2) (mildly reduced but >60)
• Lipids: total cholesterol 5.6 mmol/L, LDL 3.6 mmol/L, HDL 0.9 mmol/L, triglycerides 2.2 mmol/L (dyslipidaemia)
• ECG: sinus rhythm, no acute ischaemic changes

Diagnosis

• Primary diagnosis: Poorly controlled type 2 diabetes mellitus (HbA1c 10.2%) with early microvascular complications — peripheral neuropathy (reduced sensation, paresthesia), background diabetic retinopathy, and microalbuminuria.

  • Evidence: symptoms of polydipsia/polyuria, elevated random glucose and fasting glucose, HbA1c 10.2%; monofilament and vibration loss; fundoscopy changes; urine albumin elevated.

• Differential diagnoses to consider:

  • Medication non-adherence or suboptimal regimen (history of missed sulfonylurea doses) — could explain poor control.
  • Secondary causes of hyperglycaemia (e.g., steroids) — less likely given history and no steroid use.
  • Type 1 diabetes or LADA — unlikely given long-standing T2DM history, age, and treatment response pattern.
  • Primary renal disease causing proteinuria — creatinine and eGFR relatively preserved, pattern consistent with diabetic nephropathy.

Management

• Immediate/short-term:

  • Explain results and urgent need to improve glycemic control; discuss options including intensification of therapy.
  • Assess adherence and barriers; review medications and consider simplifying regimen.
  • Consider initiating (or intensifying) therapy: for HbA1c >9% with symptoms, discuss starting basal insulin (e.g., once-daily long-acting insulin) versus adding/optimizing other agents (e.g., consider GLP-1 receptor agonist or SGLT2 inhibitor depending on renal function and cardiovascular risk) — discuss risks/benefits and patient preference.
  • Start/optimize renin–angiotensin system blockade for albuminuria: increase lisinopril dose after monitoring renal function and potassium, or switch/augment per guidelines.
  • Intensify statin therapy and address dyslipidaemia (review atorvastatin dose; consider high-intensity statin for high CV risk).

• Monitoring and referrals:

  • Arrange diabetes nurse education for SMBG (self-monitoring of blood glucose), insulin technique if started, and dietary advice.
  • Refer to podiatry for foot care and regular review given neuropathy.
  • Urgent referral to ophthalmology/diabetic eye screening for retinopathy follow-up.
  • Smoking cessation support and discussion of weight management and structured exercise programme.
  • Repeat renal function and electrolytes after any ACE inhibitor dose change; monitor HbA1c in 3 months after treatment change.

• Preventive measures:

  • Influenza and pneumococcal vaccination as appropriate.
  • Advise on sick-day rules and when to seek urgent care (signs of hyperglycaemic emergencies, foot infections).

• Social/support:

  • Address patient concerns about insulin injections; offer practical demonstration and shared decision-making.
  • Plan follow-up appointment within 2–4 weeks after treatment changes.

Key Learning Points

• An HbA1c >9–10% with symptomatic hyperglycaemia requires timely intensification of therapy (often insulin or potent non-insulin agents) and education.
• Screen routinely for diabetic complications (retinopathy, nephropathy, neuropathy) and manage cardiovascular risk factors (BP, lipids, smoking) concurrently.
• Always assess adherence, lifestyle barriers, and patient concerns (ICE) — these influence realistic management choices and uptake of therapies such as insulin.