Quick Case Study

Patient with Diabetes Arrives at Clinic in Distress

Gap schedule, advanced practice provider training help stabilize high-risk patient

Nurse conducting a finger stick on a man

An overweight 61-year-old male with Type 2 Diabetes Mellitus (T2DM) arrived late to a Duke diabetes clinic appointment, presenting with dyspnea and complaining of chest pains after rushing from the parking lot.

The man’s late arrival presented a staffing challenge for the busy clinic, but the recent adoption of a gap schedule meant a nurse practitioner was available. The gap system frees an advanced practice provider to be available during most clinic hours to meet with late-arriving patients or respond to unexpected emergencies.

Because the patient had missed previous appointments and consistent care had not been possible, the intake process required an hour and revealed a constellation of symptoms: uncontrolled diabetes, dyspnea, sleep apnea, mood disorder, and angina potentially related to an arterial blockage.

Question: What steps did the clinical team take to engage the patient, assess his physical condition, and encourage corrective care?

Answer: The team discussed the multiple risk factors with the patient, focusing on their severity, and emphasized the possibility of a sudden cardiac event. The stern warning resonated with the patient, who responded by accepting the clinical guidance, seeking immediate cardiac assessment, becoming a regular patient, and managing his diabetes effectively with newer therapies.

The gap scheduling system, swift symptom recognition by Amanda Gammon, a family nurse practitioner with specialized endocrine training, and her direct guidance were keys to engaging and refocusing the patient on his critical health needs. Jennifer Rowell, MD, a Duke endocrinologist who works closely with Gammon in a team-based model, credits her with taking the time to explain the immediate risks.

“Amanda spent a lot of time with this patient that I would not have been able to do given the circumstances in our clinic at the time he arrived,” Rowell says. “She deserves the credit for recognizing his symptoms and getting this patient on track.”

The patient was directed to cardiovascular follow-up to review statin use and assess potential arterial blockage. He was a Duke Heart patient; in 2008, after moving to Durham, he underwent a coronary artery bypass graft.

Before moving to the area, the patient had been diagnosed with gradual onset T2DM, but he did not manage his condition effectively. He was prescribed metformin but did not consistently follow-up with endocrinologists, refused injectable insulin, and rejected wearable glucose monitoring devices.

Now a regular in the endocrinology clinic, the patient wears a sensor to monitor glucose and uses insulin as needed. A stent was inserted by cardiologists to relieve an arterial blockage. Rowell describes the individual as a changed patient with a better outlook.

“This patient was at high risk for vascular disease when he presented to Amanda,” Rowell says. “She has followed him closely. When I saw him recently he was doing well thanks to her care and involvement. This patient’s transformation is a good example of the value of both specialized training and the effective collaboration with our clinical partners.”