Diabetes Review OSCE - Diabetes Complications Discussion | Free OSCE Practice

Case Overview

Age/Sex: 72-year-old female
Occupation: Retired primary school teacher
Setting: Routine diabetes clinic / GP follow-up
Chief complaint: "Diabetes check-up"

Patient Script

Who I Am

I am 72, retired, been living at home with my husband — I used to teach primary school.

What Brings Me In

I'm here for my regular diabetes check-up — I feel a bit more tired than usual and my ankles look puffier, so I thought you should check me over.

My Story

I've had type 2 diabetes for about 18 years and I've been coming for diabetes checks regularly. Over the last 3 months I've noticed I'm a bit more tired than usual and sometimes my ankles are a bit swollen in the evening. I have to get up once or twice at night to pee which is more than before. My husband says my feet sometimes look a bit numb and I trip over the rug occasionally. I haven't had any severe chest pain or shortness of breath when walking, though I do get breathless climbing a flight of stairs compared with two years ago.

I had a urinary infection about 6 weeks ago and was given antibiotics — that cleared up. I have also had some low backache lately and have been taking ibuprofen a couple of times a week for that. I haven’t had any blood in my urine. My weight has been roughly the same, maybe down a kilogram over the last few months because I’ve been eating less.

My Medical Background

Past medical history: Type 2 diabetes x 18 years, hypertension x 15 years, high cholesterol, osteoarthritis of knees, mild diabetic retinopathy diagnosed 2 years ago
Medications: Metformin 1g twice daily, glimepiride 2 mg daily, amlodipine 10 mg daily, simvastatin 20 mg at night, aspirin 75 mg daily, paracetamol as needed, occasional ibuprofen for back pain
Allergies: None known
Social: Lives with husband, ex-smoker (stopped 20 years ago), drinks a glass of wine once or twice a week
Family: Mother had stroke in her 80s; father died of MI in his 60s

What I Think & Worry About

I think my diabetes is getting worse and I'm worried I might need dialysis one day.
I'm worried my memory and balance are getting worse and I might be a danger at home.
I'm worried about taking more tablets and about side effects of new medicines.

If You Ask Me About Other Symptoms...

Vision: I get occasional blurry spots and had an eye check 6 months ago; they said it was "background" diabetic changes.
Thirst/hunger: I feel a bit thirstier than before but not dramatically so.
Urine: No pain when passing urine now; urine was a bit cloudy 6 weeks ago with the UTI but is normal-looking mostly; sometimes my urine looks a bit foamy.
Swelling: Mostly in the ankles at the end of the day, better in the morning after elevating feet.
Breathlessness/chest pain: No chest pain; mild breathlessness on stairs, no recent paroxysmal nocturnal dyspnoea.
Neuropathy: Numbness and tingling at the tips of both feet for the past year, worse at times.
Weight/appetite: Slightly less appetite recently; no deliberate dieting.
Medication adherence: I take my tablets most days but sometimes skip the evening metformin when I’m going out for dinner.

Clinical Summary

Examination

General: Alert, comfortable at rest, no acute distress
Vitals: BP 152/88 mmHg; HR 78 bpm regular; RR 16/min; Temp 36.8°C
Height/weight/BMI: 1.58 m, 78 kg — BMI 31.3 kg/m2
Cardiovascular: Normal heart sounds; no murmurs
Respiratory: Clear to auscultation, no crackles
Abdomen: Soft, non-tender, no palpable masses
Peripheral: Mild pitting oedema to the level of the malleoli bilaterally; peripheral pulses present
Neurological: Reduced vibration sense at both great toes; decreased pinprick sensation to mid-foot bilaterally
Eyes: Background diabetic retinopathy documented on prior ophthalmology review (no recent haemorrhages reported)

Investigations

HbA1c: 8.4% (68 mmol/mol) (interpretation: suboptimal glycaemic control)
Fasting glucose: 9.5 mmol/L (high)
Serum creatinine: 110 µmol/L (interpretation: mildly raised for age; partial renal impairment)
eGFR: 52 mL/min/1.73 m2 (interpretation: CKD stage 3a)
Serum potassium: 4.6 mmol/L (within reference range)
Urine dipstick: trace protein, no nitrites, no leukocyte esterase
Urine albumin-to-creatinine ratio (ACR): 120 mg/g (≈13.6 mg/mmol) (interpretation: elevated — persistent albuminuria / diabetic nephropathy range)
Lipid profile: LDL 3.4 mmol/L, total cholesterol 5.6 mmol/L (moderately elevated)
ECG: Sinus rhythm, no acute ischaemic changes

Diagnosis

Primary diagnosis:

Diabetic nephropathy / early chronic kidney disease (CKD stage 3a) with persistent albuminuria (urine ACR elevated) in the context of long-standing type 2 diabetes and hypertension.
- Evidence: long diabetes duration (18 years), ACR 120 mg/g, eGFR 52 mL/min/1.73 m2, suboptimal BP (152/88 mmHg) and poor glycaemic control (HbA1c 8.4%).

Differential diagnoses and reasoning:

Urinary tract infection: recent UTI 6 weeks ago (red herring) but current dipstick shows no nitrites/leukocytes and symptoms resolved — less likely causing persistent albuminuria.
Heart failure: can cause peripheral oedema, but no clinical signs of pulmonary oedema, normal JVP and clear lungs argue against decompensated heart failure as the cause of albuminuria.
Non-diabetic renal disease (eg, glomerulonephritis, drug-induced): possible but less likely given long diabetes history and background retinopathy; would consider if atypical features (haematuria, rapid decline in eGFR) were present.
Medication-related (NSAID-induced): occasional ibuprofen could contribute to kidney injury, but pattern and degree of albuminuria are more consistent with diabetic nephropathy; advise stopping NSAIDs.

Management

Start renin–angiotensin system blockade: initiate an ACE inhibitor (e.g., ramipril 2.5 mg daily) or ARB if ACEi intolerant, with plan to titrate to maximize albuminuria and BP control.
- Check serum creatinine and potassium 1–2 weeks after initiation and after each dose increase.
Blood pressure target: aim for BP <130/80 mmHg if tolerated (individualise for age/comorbidities).
Glycaemic control: review glucose-lowering regimen with aim to reduce HbA1c safely (consider intensifying therapy; consider adding or reviewing insulin or SGLT2 inhibitor suitability given CKD stage and cardiovascular risk).
Lipid management: optimise statin therapy (consider increasing intensity) and counsel on cardiovascular risk reduction.
Lifestyle: advise salt restriction, fluid management, weight reduction, stop NSAIDs, and continue smoking abstinence.
Monitoring: repeat urine ACR in 3 months to assess response; monitor eGFR regularly (eg, every 3–6 months initially).
Referrals and preventive care:
- Diabetic foot review and reinforce neuropathy care and footwear.
- Ophthalmology follow-up for diabetic retinopathy as scheduled.
- Consider nephrology referral if rapid decline in eGFR, persistent heavy proteinuria, haematuria, or eGFR falls below 30 mL/min/1.73 m2.
- Offer influenza and pneumococcal vaccination as appropriate.
Patient counselling: discuss what albuminuria means, benefits/risks of starting ACE inhibitor (possible cough, monitoring of creatinine/potassium), and importance of adherence and follow-up.

Key Learning Points

Regular screening for albuminuria (urine ACR) in long-standing diabetes is essential — early detection allows intervention to slow CKD progression.
Optimal management of diabetic nephropathy includes blood pressure control (ACE inhibitor or ARB), glycaemic control, lipid management, lifestyle modification, and avoidance of nephrotoxins (eg, NSAIDs).
Not all ankle swelling or urinary symptoms indicate heart failure or UTI; integrate history, examination and investigations (ACR, eGFR, dipstick) to distinguish diabetic kidney disease from other causes.