Case Study 1: History Taking

Student: Mr Bearay what brings you into the clinic today?

Mr Bearay: I have been referred by my doctor. I am diabetic and I have problems with my feet

Student: How long have you had your diabetes for?

Mr Bearay: For ever - 25-30 years

Student: So is it controlled well? - so have you had a recent blood glucose test?

Mr Bearay: HB1C Last time was 6.9

Student: Okay that's good and did you take a blood glucose reading today or last night at all?

Mr Bearay: It was up a bit this morning at 7.1

Student: Okay and thats not normal for you?

Mr Bearay: Ahh its up and down like a yoyo

Mr Bearay: Okay and you write all this down?

Mr Bearay: Last night it was 5.1

Student: Okay good and your trying to control it? Are you on any medication at the moment?

Mr Bearay: I take insulin, novo30

Student: Just once a day?

Mr Bearay: twice a day - I test in the morning and before a meal

Student: are you on any other medication?

Mr Bearay: I have a list

• NovoMix 30 penfill 3ml
• 3mlx5x5 Insulin
• Crestor (rosuvastatin) 10mgx30 - OD notce
• Glimepiride (diapride) 4mgx30 - half a tablet (2mg in the moring immediately before food)
• Metformin (formet 100) 1000mgx90 - BD immediately after food
• Propranolol (deralin) 40mgx100) BD 2 tablets
• Prilace (Ramipril 10mgx30) - notce OD

Student: I will just ask you some other questions - with your diabetes how has it affected your feet?

Mr Bearay: I have charcot foot on both feet - actually the right is much worse than the left

Student: and when did that start?

Mr Bearay: 10 years ago

Student: and are there any other changes to your foot besides the charcot foot?

Mr Bearay: the charcot foot is quite dramatic anyway - the whole thing collapses

Student: so how is the sensation in your feet? Do you have much feeling?

Mr Bearay: there is still feeling there - when do you do your little test

Student: So you have just lost that protective sensation in your feet?

Mr Bearay: yeah

Lloyd - the student went on to ask the patient about his previous treatment for foot or lower limb problems, medical history, his surgical history, social history his work history his family history and history of allergies. He identified that the patient had had an ulcer on his left second toe twelve months ago - he had also had previous treatment for an ulcer beneath the cuboid of the left foot twelve months ago - he was diagnosed more than twenty years ago with diabetes myelitis and had experienced acute charcot arthropathy, he had an allergy to trimethoprin he has retinopathy which has affected both eyes. He has minimal social activity now due to his foot problems and he has neuropathy affecting both feet.

You can read the more detailed hospital and previous podiatry case notes in the teaching materials.

Obtaining a thorough medical history and podiatric history is part of the ANZPAC competency number four regarding conducting the client / patient interview. The second skill set in this competency domain is conducting the physical examination which is demonstrated in the next video.