I.

Introduction
The Health Service Executive describes Primary Care as a health or social care service that
one can find in his own community, outside of hospitals, ranging from General Practitioner
Service and Practice Nurse Service to Physiotherapy and Social Work Service. Since the
announcement of the Primary Care Strategy in 2001, a great deal of Primary Care Centers
was implemented throughout Ireland. I enjoyed my time in Clinic X and was fortunate
enough to be showered with a plethora of knowledge and experience by Dr X for 2 weeks
albeit feeling it was a little short-lived.
Nick Jonas: Type 1 Diabetes is a completely manageable disease. But, there are some days
that are just rough. Just know that you are not alone.
This case report will discuss about Mrs Q, a Y-year old Irish lady, who is battling
complications of Type-1 Diabetes Mellitus (T1DM) in pursuit of a decent quality of life. She
had been diagnosed with T1DM 20 years ago and had to bear and suffer from inadequate care
by incompetent and unprofessional consultants in the past before experiencing the positive
by-product of a metamorphic improvement in healthcare in Ireland during the later course of
her illness. Mrs Q deluged me with plenty of information and expressed a multitude of
emotions describing her point of view on T1DM.

II. Patient’s perspective

As advised by my GP tutor X, I went through Mrs Q’s charts through the computer a few
days prior, focusing on all referral letters, investigations, medications, and GP notes from
previous consultations. From the files, I understood that the ‘tag’ T1DM does not just end
there, but it also came with its complications – peripheral neuropathy, disturbed quality of
life, emotional stress – all of which Mrs Q had experienced ever since the start of her illness.
Apart from the struggle she has with the T1DM scene, she had to face recurrent infections
from psoriasis all over her body.
Being the over excessively nervous medical student that I am, I mustered up the courage to
begin my task and escorted Mrs Q from the waiting area into the room when I noticed a
subtle limp on her right leg to which she explained the sensation on her feet to be “a sharp
pain, but it is as if it is burning, but numb too, if that makes sense. It would go very cold. It is
really strange”. This pain started in 2018 and it hinders her from walking far distances as she
would have normally been able to a few years ago. She used to be able to exercise regularly
but she is incapable to do so now because of the extreme pain. She stated that T1DM and its
complications are all a part of “a harmful cycle” that affected and “ruined” her whole life.
She was stressing about how she is unable to exercise efficiently – one of the best lifestyle
methods that can help her disease to progress slower. Knowing that Mrs Q walks almost 30
minutes to and from her workplace, I cannot begin to fathom the kind of pain she experiences
daily. When asked about how she copes with it, she responded that it was necessary for her to
earn a living to support her family. “I got very down, and I thought I could not cope anymore.
It’s so bad, but I cannot bear it if my family has nothing to eat”.
The pain on her feet impacted her not just physically, but socially too. She would decline
invitations to go out for drinks with her friends because she is incapable of standing or
walking for long hours. Besides that, Mrs Q feels somewhat humiliated when she must
excuse herself to the toilet so that she can get that little privacy to inject insulin into her
abdomen. Over the past year, her friends secluded her from outings and parties. Mrs Q
believes the reason that happens is that she had declined invitations numerous times in the
past to the extent by which her friends saw no reason to invite her anymore. Now, after
realising how common T1DM is, Mrs Q does not bother hiding her need for medications
from her friends. She mentions openly the need to take insulin and excuses herself. There is a
clear reorientation of her mindset regarding T1DM after 2 decades of education.
Mrs Q was diagnosed with T1DM during her pregnancy at 20 weeks. She was given insulin
during her pregnancy and was subsequently switched to a tablet medication for 6 weeks with
an impression that it would resolve. She ate the medication religiously but when she went for
follow-up, the doctors told her she was not improving and diagnosed her with T1DM.
“That was it. I’m stuck with this burden. For life.”
I will never forget these ten powerful words muttered by Mrs Q as it shows how devastating
to life and shocking it is when one is diagnosed with a chronic illness. This was when I
realised she was not just my assignment, but she is a human being, with a life worth living,
just like any one of us.
Mrs Q was then discharged for outpatients’ review and was seen under a consultant K. She
was petrified by the thought of having to go for follow-ups because she felt intimidated when
Dr K would interpret her blood glucose readings in front of her, criticize every aspect of her
lifestyle and comment on how everything she does to manage her diabetes was ‘a mistake’.
“If you had Diabetes, and a doctor tells you off, you would cry because it is stressful – and I
did”.
She was also not offered and educated about the DAFNE program up until a few years ago
and felt disappointed in the Irish healthcare system. Mrs Q had to learn how to ‘carb count’
all by herself from the extensive research she did online.
However, prior to self-education on self-management techniques, I felt as if Mrs Q was
thrown into a dark corner. She did not balance carbohydrate intake and insulin shots well
which resulted in four hypoglycaemic-unawareness a day in the later stages of her illness. At
the time, she was not aware that there was such a thing as hypo-unawareness so she panicked
every time she sees a high blood glucose reading as she is afraid it might ‘damage’ her,
causing her to either inject more insulin or eat less carbohydrates.
Having both T1DM and psoriasis pose a great deal of stress psychologically to Mrs Q
because with these illnesses comes the responsibility of medication compliance. She thinks it
is hard to “juggle too many things” on her mind. She complains about having missed insulin
shots rarely because she is just too tired to fetch the pen and to inject it. However, she would
miss out on her Betacap and Penicillin treatment for her psoriasis often because she thinks it
is not as severe as her diabetes.
“I love my daughter and my family and will fight for them by eating and trying my best to
exercise well. Doing that, I think I will be grand, and I will not let diabetes take me.”
The quote above by Mrs Q speaks volume about her resilience living with T1DM. She talks a
lot about her Y-year-old daughter living with her. I could sense a hint of vulnerability deep
down when she starts blaming herself for the heart malformation her daughter has. Her
explanation of how her maternal diabetes caused the defects in her daughter’s heart
accompanied by her shaky voice and teary eyes speaks a lot about how T1DM can impact
someone psychologically.
I was fortunate enough to have a quick interview with HQ, Mrs Q’s daughter. She describes
Mrs Q as a strong, loving mother who tries very hard to give the best for her family. She
mentions that it might be a little tough sometimes as she must occasionally help clean her
mother’s feet to prevent any feet infection. She would occasionally remind her mother to take
insulin jabs during a meal. HQ never forgets to keep with her some sugary sweets and drinks
every time they go out together, because she is “worried mom might collapse”. HQ studies in
NUI Galway and on some days, she feels worried if her mother does not reply her texts as she
is worried about hypoglycemia, even though “she is probably taking a nap”. Nevertheless,
she states that caring for her mother is a responsibility that one should cherish.

III. GP’s perspective

It was apparent from the beginning that Mrs Q and Dr X shared a close and unique
patient-doctor relationship that I had never seen before. Mrs Q puts all her faith in
Dr X because she states that Dr X is the first doctor to establish a “respectful,
professional, warm and cozy” rapport with her. Their almost telepathic doctor-
patient rapport is unreal, and it is something I will take as an exemplar when
molding myself as a doctor.

My GP describes Mrs Q as a patient who was treated unjustifiably when she was
first diagnosed with T1DM. She expressed admiration towards Mrs Q for showing
trust in the Irish healthcare system after seeing such a rude doctor rebuking her
actions. Dr X acts as a personal confidant to Mrs Q much like how Tom Hagen
was consigliere to the Corleone family in The Godfather. Dr X would counsel Mrs
Q on healthy lifestyles at each consultation just like how Consultant K would,
except that she did not do it in a condescending or rude tone. Dr X would comfort
Mrs Q about the issue regarding her daughter’s heart defect – in that it is not her
fault and her daughter is very well managed while living an excellent quality of
life.

One of the struggles my doctor faced was that she hoped she could get more than
15 minutes of consultation with Mrs Q. She felt that Mrs Q deserves more time to
establish an even closer rapport than what they already have. Also, Dr X informed
me that it was quite a struggle getting Mrs Q to change her habits about diet and
exercise at the start. All these problems stem from the inappropriate consultation
she received during the earliest stage of her illness.

Another struggle my tutor faced throughout her history with Mrs Q revolves
around the fact that she is unable to properly classify Mrs Q under a class of
Diabetes Mellitus. She called it “Diabetes Type-1.5” – more formally known as
 Latent Autoimmune Diabetes in Adults (LADA). To classify her correctly, many
predicaments must be answered - Is LADA different pathophysiologically from
classic childhood type 1 diabetes or is LADA merely type 1 diabetes presenting at
an older age? Would that have an impact in the management of Mrs Q? If her
insulin therapy is working, would we emphasize on finding out the nitty-gritty
details within a grey area? Dr X struggles with the debate of T1DM and LADA
herself, but strives to ensure that regardless of the essentials of the problem, Mrs
Q must be properly managed and excellent quality primary care must be given.

I believe that the management plan formulated by my tutor is a logical plan that
follows the plan NICE guidelines has set in place for doctors – stressing on dietary
management, physical activity, blood glucose management and insulin therapy. I
felt relieved when I heard that Mrs Q was prescribed Neurontin which
successfully alleviated some of her pain in her feet. A suggestion that I would
make in terms of managing Mrs Q would be a fundoscopy to screen for
retinopathy. According to the Framework for the Development of a Diabetic
Retinopathy Screening Program for Ireland, as much as 6 % of patients are
prevented from blindness within one year of treatment, and 34% within 10 years
of treatment. Despite not having any complaints about her vision, I am certain that
checking for all microvascular and macrovascular complications of diabetes is
empirical to ensure good outcome and to catch any progression of the disease
early.

IV. My Perspective
I. Introduction
The Health Service Executive describes Primary Care as a health or social care service that
one can find in his community, outside of hospitals, ranging from General Practitioner
Service and Practice Nurse Service to Physiotherapy and Social Work Service. Since the
announcement of the Primary Care Strategy in 2001, a great deal of Primary Care Centers
was implemented throughout Ireland. I enjoyed my time in Clinic X and was fortunate
enough to be showered with a plethora of knowledge and experience by Dr. X for two weeks,
albeit feeling it was a little short-lived.
Nick Jonas: Type 1 Diabetes is a completely manageable disease. But, some days are just
rough. Just know that you are not alone.
This case report will discuss Mrs. Q, a Y-year old Irish lady, who is battling complications of
Type-1 Diabetes Mellitus (T1DM) in pursuit of a decent quality of life. She had been
diagnosed with T1DM 20 years ago and had to bear and suffer from inadequate care by
incompetent and unprofessional consultants in the past before experiencing the positive by-
product of a metamorphic improvement in healthcare in Ireland during the later course of her
illness. Mrs. Q deluged me with plenty of information and expressed a multitude of emotions
describing her point of view on T1DM.

II. Patient’s perspective

As advised by my GP tutor X, I went through Mrs. Q’s charts through the computer a few
days prior, focusing on all referral letters, investigations, medications, and GP notes from
previous consultations. From the files, I understood that the ‘tag’ T1DM does not just end
there, but it also came with its complications – peripheral neuropathy, disturbed quality of
life, emotional stress – all of which Mrs. Q had experienced ever since the start of her illness.
Apart from the struggle she has with the T1DM scene, she had to face recurrent infections
from psoriasis all over her body.
Being the over excessively nervous medical student that I am, I mustered up the courage to
begin my task and escorted Mrs. Q from the waiting area into the room when I noticed a
subtle limp on her right leg to which she explained the sensation on her feet to be “a sharp
pain, but it is as if it is burning, but numb too, if that makes sense. It would go very cold. It is
really strange”. This pain started in 2018, and it hinders her from walking far distances as she
would have usually been able to a few years ago. She used to be able to exercise regularly,
but she is incapable of doing so now because of the extreme pain. She stated that T1DM and
its complications are all a part of “a harmful cycle” that affected and “ruined” her whole life.
She was stressing about how she is unable to exercise efficiently – one of the best lifestyle
methods that can help her disease to progress slower. Knowing that Mrs. Q walks almost 30
minutes to and from her workplace, I cannot begin to fathom the kind of pain she experiences
daily. When asked about how she copes with it, she responded that she needed to earn a
living to support her family. “I got very down, and I thought I could not cope anymore. It’s so
bad, but I cannot bear it if my family has nothing to eat”.
The pain on her feet impacted her not just physically, but socially too. She would decline
invitations to go out for drinks with her friends because she is incapable of standing or
walking for long hours. Besides that, Mrs. Q feels somewhat humiliated when she must
excuse herself to the toilet so that she can get that little privacy to inject insulin into her
abdomen. Over the past year, her friends secluded her from outings and parties. Mrs. Q
believes the reason that happens is that she had declined invitations numerous times in the
past to the extent by which her friends saw no reason to invite her anymore. Now, after
realising how prevalent T1DM is, Mrs. Q does not bother hiding her need for medications
from her friends. She openly mentions the need to take insulin and excuses herself. There is a
definite reorientation of her mindset regarding T1DM after 2 decades of education.
Mrs. Q was diagnosed with T1DM during her pregnancy at 20 weeks. She was given insulin
during her pregnancy and was subsequently switched to a tablet medication for six weeks
with an impression that it would resolve. She ate the medicine religiously, but when she went
for follow-up, the doctors told her she was not improving and diagnosed her with T1DM.
“That was it. I’m stuck with this burden. For life.”
I will never forget these ten powerful words muttered by Mrs. Q as it shows how devastating
to life and shocking it is when one is diagnosed with a chronic illness. This was when I
realised she was not just my assignment, but she is a human being, with a life worth living,
just like anyone of us.
Mrs. Q was then discharged for outpatients’ review and was seen under a consultant K. She
was petrified by the thought of having to go for follow-ups because she felt intimidated when
Dr. K would interpret her blood glucose readings in front of her, criticize every aspect of her
lifestyle, and comment on how everything she does to manage her diabetes was ‘a mistake.’
“If you had Diabetes, and a doctor tells you off, you would cry because it is stressful – and I
did.”
She was also not offered and educated about the DAFNE program up until a few years ago
and felt disappointed in the Irish healthcare system. Mrs. Q had to learn how to ‘carb count’
all by herself from the extensive research she did online.
However, before self-education on self-management techniques, I felt as if Mrs. Q was
thrown into a dark corner. She did not balance carbohydrate intake and insulin shots well,
which resulted in four hypoglycaemic-unawareness a day in the later stages of her illness. At
the time, she was not aware that there was such a thing as hypo-unawareness, so she panicked
every time she sees a high blood glucose reading as she is afraid it might ‘damage’ her,
causing her to either inject more insulin or eat fewer carbohydrates.
Having both T1DM and psoriasis pose a great deal of stress psychologically to Mrs. Q
because with these illnesses comes the responsibility of medication compliance. She thinks it
is hard to “juggle too many things” on her mind. She complains about having missed insulin
shots rarely because she is just too tired to fetch the pen and to inject it. However, she would
miss out on her Betacap and Penicillin treatment for her psoriasis often because she thinks it
is not as severe as her diabetes.
“I love my daughter and my family and will fight for them by eating and trying my best to
exercise well. Doing that, I think I will be grand, and I will not let diabetes take me.”
The quote above by Mrs. Q speaks volumes about her resilience living with T1DM. She talks
a lot about her Y-year-old daughter living with her. I could sense a hint of vulnerability deep
down when she starts blaming herself for the heart malformation her daughter has. Her
explanation of how her maternal diabetes caused the defects in her daughter’s heart,
accompanied by her shaky voice and teary eyes, speaks a lot about how T1DM can impact
someone psychologically.
I was fortunate enough to have a quick interview with HQ, Mrs. Q’s daughter. She describes
Mrs. Q as a strong, loving mother who tries very hard to give the best for her family. She
mentions that it might be a little tough sometimes as she must occasionally help clean her
mother’s feet to prevent any feet infection. She would occasionally remind her mother to take
insulin jabs during a meal. HQ never forgets to keep with her some sugary sweets and drinks
every time they go out together because she is “worried mom might collapse.” HQ studies in
NUI Galway, and on some days, she feels worried if her mother does not reply to her texts as
she is concerned about hypoglycemia, even though “she is probably taking a nap.”
Nevertheless, she states that caring for her mother is a responsibility that one should cherish.

III. GP’s perspective

It was apparent from the beginning that Mrs. Q and Dr. X shared a close and unique patient-
doctor relationship that I had never seen before. Mrs. Q puts all her faith in Dr. X because she
states that Dr. X is the first doctor to establish a “respectful, professional, warm, and cozy”
rapport with her. Their almost telepathic doctor-patient rapport is unreal, and it is something I
will take as an exemplar when molding myself as a doctor.

My GP describes Mrs. Q as a patient who was treated unjustifiably when she was first
diagnosed with T1DM. She expressed admiration towards Mrs. Q for showing trust in the
Irish healthcare system after seeing such a rude doctor rebuking her actions. Dr. X acts as a
personal confidant to Mrs. Q, much like how Tom Hagen was consigliere to the Corleone
family in The Godfather. Dr. X would counsel Mrs. Q on healthy lifestyles at each
consultation, just like how Consultant K would, except that she did not do it in a
condescending or rude tone. Dr. X would comfort Mrs. Q about the issue regarding her
daughter’s heart defect – in that it is not her fault, and her daughter is very well managed
while living an excellent quality of life.

One of the struggles my doctor faced was that she hoped she could get more than 15 minutes
of consultation with Mrs. Q. She felt that Mrs. Q deserves more time to establish an even
closer rapport than what they already have. Also, Dr. X informed me that it was quite a
struggle getting Mrs. Q to change her habits about diet and exercise at the start. All these
problems stem from the inappropriate consultation she received during the earliest stage of
her illness.

Another struggle my tutor faced throughout her history with Mrs. Q revolves around the fact
that she is unable to classify Mrs. Q under a class of Diabetes Mellitus accurately. She called
it “Diabetes Type-1.5” – more formally known as Latent Autoimmune Diabetes in Adults
(LADA). To classify her correctly, many predicaments must be answered - Is LADA
different pathophysiologically from classic childhood type 1 diabetes or is LADA merely
type 1 diabetes presenting at an older age? Would that have an impact on the management of
Mrs. Q? If her insulin therapy is working, would we emphasize on finding out the nitty-gritty
details within a grey area? Dr. X struggles with the debate of T1DM and LADA herself but
strives to ensure that regardless of the essentials of the problem, Mrs. Q must be
appropriately managed, and excellent quality primary care must be given.

I believe that the management plan formulated by my tutor is a logical plan that follows the
plan NICE guidelines have set in place for doctors – stressing on dietary management,
physical activity, blood glucose management, and insulin therapy. I felt relieved when I heard
that Mrs. Q was prescribed Neurontin, which successfully alleviated some of her pain in her
feet. A suggestion that I would make in terms of managing Mrs. Q would be a fundoscopy to
screen for retinopathy. According to the Framework for the Development of a Diabetic
Retinopathy Screening Program for Ireland, as much as 6 % of patients are prevented from
blindness within one year of treatment, and 34% within 10 years of treatment. Despite not
having any complaints about her vision, I am certain that checking for all microvascular and
macrovascular complications of diabetes is empirical to ensure a good outcome and to catch
any progression of the disease early.