Diabetes Review OSCE - New Type 2 Diabetes Diagnosis

Case Overview

• Age/Sex: 53-year-old female
• Occupation: Office worker (administrative assistant)
• Setting: Primary care clinic — routine "diabetes check-up" appointment requested by patient
• Chief complaint: "I think I need a diabetes check-up — I've been thirsty and going to the toilet a lot for a few months."

Patient Script

Who I Am

I'm 53, I work in an office doing paperwork and meetings, and I live with my husband.

What Brings Me In

I've been really thirsty and peeing more than usual for the last few months, so I thought I should get my sugar checked.

My Story

For about the past 3 months I've noticed I'm thirstier than usual and needing to use the bathroom during the day and once at night — at first just once, now about 4–5 times during the day and once at night. I also feel tired most afternoons and sometimes have a little blurred vision, especially after long computer sessions. I haven't had any dramatic weight loss — in fact I've put on a few kilos over the last year because I sit at a desk and snack a lot. I had a sore on my toe a few months ago that took a long time to heal and I once had a vaginal yeast infection last month that my GP treated with a course of antifungal pessaries. I started a short "detox" juice plan for a week two weeks ago and lost a kilo, but I stopped because it made me light-headed.

I noticed my mother had "sugar" when she was older and she took tablets for it. I don't take any sugar pills myself.

My Medical Background

• Past medical history: hypertension (diagnosed 5 years ago), high cholesterol
• Medications: lisinopril 10 mg once daily, simvastatin 20 mg at night; occasional ibuprofen for knee ache
• Allergies: none known
• Social: ex-smoker (stopped 10 years ago, smoked ~10 cigarettes/day previously); drinks socially (about 5–8 units/week); works full-time, mostly sitting; limited regular exercise
• Family: mother had type 2 diabetes; father died of heart attack in his 70s
• Recent events (red herrings): completed a 1-week juice "detox" 2 weeks ago; treated for a presumed urinary infection 3 months ago with a 3-day course of antibiotics

What I Think & Worry About

• I think I might have diabetes — my mother had it and the symptoms sound similar.
• I'm worried I might need injections or that this could lead to complications like needing my eyesight checked or having a heart problem.
• I worry about changing my diet and keeping up with work if I have to change things.

If You Ask Me About Other Symptoms...

• Chest pain: I get tightness if I climb stairs quickly, but no crushing chest pain.
• Shortness of breath: a bit breathless when hurrying upstairs, otherwise fine.
• Vision: intermittent blurred vision after long computer use, clears after resting.
• Numbness/tingling: sometimes my toes feel a bit numb at the end of the day.
• Weight: gained about 4–5 kg over the last year; lost 1 kg on that short juice plan two weeks ago.
• Appetite: not really changed — I snack at work (biscuits, tea).
• Urinary symptoms: more frequent urination and some urgency; no pain with peeing currently. I had a UTI treated 3 months ago.
• Sleep: sleep is disturbed due to needing to get up once at night to pee.
• Medications: take lisinopril and statin regularly; sometimes take ibuprofen for knee pain.

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Clinical Summary

Examination

• General: overweight middle-aged female, alert and oriented
• Height/Weight/BMI: 1.63 m, 85 kg, BMI 32 kg/m2
• Waist circumference: 98 cm
• BP: 148/92 mmHg (sitting, right arm)
• Pulse: 84 bpm, regular
• Respiratory rate: 14/min, afebrile
• Random capillary blood glucose (clinic): 16.2 mmol/L (292 mg/dL)
• Cardiovascular: normal heart sounds, no murmurs
• Respiratory: clear to auscultation
• Abdomen: soft, non-tender
• Eyes: visual acuity reduced slightly at distance with blurring on prolonged focus; no overt retinal hemorrhages on basic fundoscopy performed in clinic (limited view)
• Lower limb: peripheral pulses palpable (2+), no ulceration; reduced vibration sense at toes bilaterally (mild peripheral neuropathy)
• Skin: mild acanthosis nigricans on the posterior neck; no obvious fungal intertrigo at exam

Investigations

• Random capillary glucose (clinic): 16.2 mmol/L (hyperglycaemia)
• Fasting plasma glucose: 9.8 mmol/L (176 mg/dL) (elevated; diagnostic threshold ≥7.0 mmol/L)
• HbA1c: 8.2% (66 mmol/mol) (elevated; diagnostic threshold ≥6.5%)
• Lipid profile: total cholesterol 5.6 mmol/L, LDL 3.5 mmol/L, HDL 1.0 mmol/L, triglycerides 2.1 mmol/L (atherogenic pattern)
• Serum creatinine: 78 µmol/L, eGFR 88 mL/min/1.73 m2 (renal function preserved)
• Liver function tests: ALT 26 U/L (within reference)
• Urine dipstick: glucose ++, ketones negative
• Urine albumin-to-creatinine ratio (ACR): 45 mg/g (elevated — microalbuminuria)
• ECG: sinus rhythm, no acute ischemic changes

Diagnosis

• Primary: New diagnosis of Type 2 diabetes mellitus

  • Evidence: Typical symptoms of polyuria, polydipsia, fatigue for ~3 months combined with confirmatory abnormal plasma glucose values (fasting glucose 9.8 mmol/L) and raised HbA1c 8.2%.

• Differentials considered:

  • Type 1 diabetes mellitus: less likely given age (53), gradual onset, presence of obesity and insulin resistance signs (acanthosis), negative ketones, and preserved renal function.
  • Secondary causes of hyperglycaemia (e.g., steroid-induced): unlikely — no current steroid use.
  • Urinary tract infection causing frequency: possible contributor historically (treated 3 months ago) but current urinary frequency accompanied by polydipsia and hyperglycaemia points to diabetes.
  • Diabetes insipidus: unlikely because patient has hyperglycaemia and glucosuria.

Management

• Confirm diagnosis explained to patient: symptoms + HbA1c ≥6.5% — diagnosis of type 2 diabetes confirmed.
• Immediate pharmacologic therapy:
  • Start metformin modified-release 500 mg once daily with food, titrate up to 2 g daily as tolerated (ensure no contraindication; eGFR 88 mL/min/1.73 m2 so metformin appropriate).
• Lifestyle and education:
  • Structured diabetes education referral (dietary advice, carbohydrate counting basics, physical activity plan — aim for 150 minutes moderate activity/week).
  • Advice on weight reduction strategies and reducing sugary snacks at work.
• Complications screening and prevention:
  • Urgent referral to diabetic eye screening service for retinal assessment.
  • Foot care education and arrange annual foot review; stringently inspect feet at follow-ups for any ulcers.
  • Start or continue statin therapy (patient on simvastatin — ensure adherence and consider intensity according to CV risk).
  • Blood pressure control: review lisinopril dose and reinforce target BP <140/90 (consider dose uptitration or add-on agent if persistent hypertension).
  • Microalbuminuria (ACR 45 mg/g): optimize RAAS blockade (continue lisinopril; consider uptitration) and repeat ACR in 3 months.
• Baseline and follow-up monitoring:
  • Baseline LFTs and repeat within 3 months after metformin titration.
  • Check HbA1c in 3 months to assess response to therapy and titration.
  • Provide glucose self-monitoring advice: not routinely needed for all patients on metformin alone, but useful around symptomatic periods and for education; offer finger-prick training if indicated.
• Vaccinations: offer annual influenza vaccine and pneumococcal vaccine as per local guidance.
• Safety and red flags:
  • Educate about symptoms of hypoglycaemia and when to seek urgent care.
  • Discuss when to seek urgent care for signs of infection or foot problems.
• Arrange follow-up in 2–4 weeks to review tolerance of metformin and blood pressure, and in 3 months for HbA1c and review of targets.

Key Learning Points

• Type 2 diabetes can present gradually with polyuria, polydipsia, fatigue and mild visual symptoms; diagnosis is made with elevated fasting glucose/HbA1c in the context of typical symptoms.
• Initial management includes lifestyle modification and metformin (if renal function allows), assessment for microvascular complications (eyes, feet, kidneys), and cardiovascular risk management (BP and lipids).
• Look for and interpret red herrings (recent short-term diet change, prior UTI, short courses of antibiotics) but use objective tests (glucometer, fasting glucose, HbA1c) to confirm the diagnosis.