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Case by Professor Omar Hasan Kasule Sr. for Year 1 Semester 1 Biomed PPSD session on 21st August 2008
Background
A 45-year old civil servant went for a medical examination required as part of the promotion exercise carried out by the department. His urine tested positive for sugar and the doctor suggested further investigations including a glucose tolerance test. Fearing to know the diagnosis, the patient refused any further investigations and instead went to consult traditional healers who gave him herbal treatments for ‘sugar’. Six months later he was not feeling well but had no specific complaint. His wife noticed that he was drinking a lot of water and was waking up at night more than usual to pass urine (polyuria & nocturia). His appetite also increased (polyphagia) especially for sweet foods. He gained weight and became lazier and fatigued easily. He went to the optician because his vision was blurred. The optician finding no specific problem prescribed reading glasses for him. The wife was worried and forced him to go to the health center where a random glucose measurement was 10.0 mmol/L. The doctor advised him to come back for a GTT and also gave him some dietary advice. The patient did not come back for the next 3 months. The wife being worried about him forced him to go for a GTT which showed a fasting plasma glucose of 6.5mmol/L and 10 mmol/L 2 hours after a glucose load. The doctor insisted that the patient attend the diabetic clinic regularly and comply with dietary advice. The patient did not comply for the next 6 months. The wife was frustrated and called a meeting of the extended family who forced the patient to attend the clinic where a repeat GTT showed a fasting glucose level of 8,0 mmol/L and a level of 12.0 mmol/L 2 hours after a glucose load. The doctor made a definitive diagnosis of diabetes mellitus and asked the patient to start attending the diabetic clinic. The patient refused and said that God would take care of him. Four months later the patient was brought to the emergency room by his work colleagues after collapsing at work. On examination he complained of nausea and gave a history of vomiting several times that day. He had abdominal pain and complained of leg cramps. On examination he was found dehydrated with hypotension. His skin was cold and clammy. He was confused and was drifting into coma. He had difficulty breathing. A urine test carried out in the emergency room was strongly positive for ketone bodies.
Discussion:
1. List the medical problems of the patient.
2. Describe the possible underlying reasons for the patient’s non-compliance with medical advice.