As part of the McMaster Physician Assistant Education Program curriculum, each student shadows a professional in the field relevant to the unit being studied that month. These are called IER placements and students are assigned a half-day shift at a hospital/clinic in Hamilton. IER stands for Interviewing, Examining, and Reasoning.
For this IER Placement:
- Medical Foundation Unit: Endocrinology
- Professional Shadowed: Nurse Practitioner – C.P.
- Date of Placement: Thurs. Feb 26, 2015
- Where: St. Joeseph’s Diabetes Clinic West 5th Campus
Read more about what I learned in my placement!
Seeing Patients with C.P., Nurse Practitioner
For this placement, I followed a nurse practitioner. With C.P., one of the first things she asked me was “What would you like to do in this placement? Do you just want to watch or do you want me to be mean and quiz you?”. I shared what I wanted to take out of this experience: if there’s an opportunity to practice examination skills, let me do so, and definitely quiz me! This is a place for learning and it’s a place where mistakes are okay. I rather make them now, learn from them than do it the hard way after graduating from the program.
Throughout the whole shift, we only saw 1 patient out of the 4 scheduled because the other 3 rescheduled! “This is why people have chronic diseases because they don’t show up for their appointments!”, C.P. joked.
C.P. tried to make my placement more worthwhile though. We went over how to diagnose diabetes mellitus, screening in annual physical exams, and also management.
What is Diabetes Mellitus?
In the simplest explanation:
- We need GLUCOSE to make ATP (energy). No glucose = no energy
- Cells need to bring glucose into them in order to metabolize it into ATP (energy)
- To do this, insulin is needed to activate glucose receptors on the cell
- No insulin => no glucose receptors on cells => no glucose being taken into the cell
- We get glucose from our diet but without insulin to bring it into cells, it will just stay in the blood stream and cause damage to blood vessels.
- Insulin is made and released by beta-cells in the pancreas
Diabetes Mellitus is a disorder where the person is hyperglycemic (too much glucose in the blood…and not in cells) because there’s no insulin or cells are not responding to insulin.
- In Type 1 Diabetes Mellitus:
- There is autoimmune destruction of the beta-cells in the pancreas.
- No beta cells => no insulin => no glucose being taken into cells => no energy
- ABSOLUTE INSULIN DEFICIENCY
- This usually presents in younger people, generally lean because the body is burning fat and protein to use as energy since cells cannot use the glucose
- In Type 2 Diabetes Mellitus (MOST COMMON)
- There is insulin resistance where cells are not responding to insulin. There’s also some insulin deficiency due to beta cell exhaustion from pumping out so much insulin.
- Lots of glucose in blood => pancreas releases lots of insulin => cells get use to the high level of insulin in the blood that it needs more insulin to respond (insulin resistance) => pancreas needs to make even more insulin that it eventually exhausts and stops making as much => not enough insulin => no glucose being taken into cells => no energy
- There is a strong genetic component in Type 2 Diabetes. Presents mostly in overweight people.
Screening in Annual Physical Exams
*Disclaimer! This following is from MY OWN understanding. For definitive measures, please Canadian Diabetes Association.
- EYE – Retinopathy: Have them check up with their optometrist or ophthalmologist
- FOOT – Neuropathy: Preform a diabetic foot exam. Positive for neuropathy is scoring <6/10
- KIDNEY – Nephropathy: Check their creatinine and creatinine clearance; also do a urine albumin/creatinine ratio
- For men – Erectile Dysfunction: Inquire about problems with intercourse
Macrovascular (increased risk for cardiovascular diseases)
Monitor the following:
- Blood Pressure
- Lipid Profile
- Glucose and HbA1C
Diagnosis can be made on abnormal value on any one of these tests
- Fasting glucose > 7.0 mmol/L
- Randon glucose > 11.1 mmol/L
- Oral Glucose Tolerance Test > 11.1 mmol/L
- HbA1C > 6.5%
Although I only got to see ONE patient with C.P., this placement is one of my favourite. In this placement, I got the opportunity to learn about what C.P. does as a nurse practitioner in a diabetes clinic, how she follows up and monitor her patient’s progress, etc. I find these observerships to be more rewarding when my preceptor made sure I left learning something new.