sdh

[vijendra singh]

Mr. X is a 60yr old gentleman with Hx of HIV, Non-ischemic systolic heart failure, uncontrolled DM, HIV associated non-Hodgkins lymphoma s/p chemo now in remission was seen in the clinic as a routine visit. His HbA1c was up trending, Mr. X was not willing to take insulin, his excuse was it’s too much for him to add a new medication. In last 6 months he has multiple admissions for CHF exacerbation, but none in last 2 months. He was happy and seem grateful that he has taken good care of his CHF in last 2 months.His Diuretic requirement is down now. Most recent HbA1c is 12.3, He is only on glipizide as his CHF precludes the use of metformin and insurance for other oral medications. Since last 2 visits, Mr. X was claiming that he is checking his blood sugars and they are well controlled, though he was not checking them at all. We discussed with the patient that he will need insulin for his diabetes control, In fact, his hyperglycemia-induced polyurea could be a factor for decrease diuretic requirement. Even after due counseling he was reluctant to start insulin. We even offered him simpler regimen like one-time glargine use, but he was not ready.
In the end, he opened up and answered he is fearful of needles and can not self-administer insulin by self. He lives with his sister. We tried to reach her in case she can help him for few days and then he can get adapted to it and start self-administering.
His sister was not reachable, fortunately as a part of tolen park (All HIV patient) so the patient has an assigned care coordinator, She was contacted and she will make sure that on next visit patient,s sister will visit with him or we will have some alternative help.
Patient social support is very helpful in patient care, Hope his sister will help him in his insulin administration.

[Dr. Nnodim]

Vijendra, thank you for a nice reflection. Wow, it seems like you really worked hard to work with this patient. Kudos to you for digging deep till you uncovered his fear which was the main barrier preventing his adherence to his insulin regimen. As you said, fortunately, the practice you were working with has a care coordinator who can help with social support coordination regarding his sister. I’m curious as to what you would have done differently if you were at another practice setting without a care coordinator? How would you advice your colleagues in such settings to address a similar situation? Also how did it make you feel to deal with this sort of issue?

[Author]

Posts