Virtual management of severe hyperglycemia
Some doctors may be surprised at the scope of practice for Virtual Primary Care. I've previously highlighted how Virtual Primary Care was lifesaving for the initial diagnosis and directed management of a gentleman with advanced testicular cancer . Now I'd like to describe the outcome of virtual care management of a patient who presented with diabetes that was wildly out of control.?
This patient, who I'll call Frank, first consulted with me via video visit in early August, asking for a checkup because he did not feel well. He complained of poor balance and the sensation when he walked that his feet were slapping on the ground. After taking a careful history and performing a video examination, I discovered that he had been a severely obese man (weight > 400lbs, BMI>50), and had a previous diagnosis of type II diabetes (T2DM). He had stopped taking metformin two years ago because it gave him diarrhea —?and had not seen a doctor since then. He undertook a remarkable weight loss journey over that two-year period, without help from any GLP-1 or other weight-loss medication. He stuck to a calorie-restricted diet and walked regularly. He had managed to lose more than 140lbs! He dropped from more than 400lbs to 259lbs. At 6' 3", his BMI was down to 32.4 kg/m^2(class I obesity). But he did not feel well.?
I advised him his blood sugar was likely out of control and he was likely suffering from diabetic neuropathy, and ordered blood and urine testing to find out what was going on. I guided him to the selection of a home glucose meter. He went to a Quest personal service center for sample collection, and Quest reported back to me that his fasting blood sugar was 343 mg/dl, and his HbA1C was 13.3%.?Fortunately his renal function was intact (Cr 1.3) and urine showed only trace protein (and trace ketones, 3+ glucose). I prescribed a long-acting insulin and arranged a quick followup virtual visit. I saw him via video two days later, instructed him (along with his wife) on how to give himself insulin injections, and he gave himself his first injection under my direct (video) supervision.
Over the following days he reported back to me via text messages, interspersed with followup video appointments, and we gradually increased his insulin treatment. He entered his fingerstick blood sugar readings directly into his chart for me to review. I added a second before-dinner injection and taught him how to manage his insulin therapy. We gradually increased his insulin doses, and he avoided any episodes of hypoglycemia (low blood sugar) as his blood sugars gradually fell to normal levels. By the end of September (six weeks after his first visit), he reported great symptomatic improvement. He no longer had difficulty with his balance, said he feels normal when walking and now feels dramatically better overall.
Frank's average blood sugar level was down to 100 mg/dl. If he continues at this level, his HbA1C will fall to below 5.6%, in the normal range for people who do not have diabetes! More important, if he maintains this treatment, he will dramatically reduce his elevated risk of complications associated with persistently high blood sugars —?from nerve damage (neuropathy) to blindness (retinopathy), kidney failure (nephropathy), stroke (cerebrovascular accidents) and heart attacks (coronary artery disease and myocardial infarction).
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With the primary problem causing his symptoms under control, Frank is back on his daily hiking and continuing his calorie-restricted healthy diet; he's now ready to address all the other ways he can lead a healthy happy life.
Frank's case. shows the power of virtual primary care to solve many serious medical problems in the most efficient —?and economical — way possible. Over a 6-week episode of treatment, Frank's care required just 8 video visits and multiple back and forth text messages.
This is an example of what can be done via virtual primary care. Here are three more articles that describe the benefits, the power, and the scope of what's possible when you connect with a doctor who cares for you in the Virtual Primary Care clinic:
Further reading:?