A.J.
You are on your orthopedic surgery rotation. You are at your staff's office when you meet A.J., a 55 year-old man of First Nations descent. He is presenting for a six-month follow-up of his right below-knee amputation. His post-operative course was complicated by several infections, likely secondary to his poorly-controlled Type 2 Diabetes Mellitus. You check his chart and note that “no fixed address” is listed in his demographic information. He states he has been living in a convalescent wing of a local shelter to recover from his surgery and the post-operative wounds that ensued. He relies on the use of a wheelchair for ambulation, provided by the shelter.
Resources, unless otherwise noted (links provided at bottom of page):
Resources, unless otherwise noted (links provided at bottom of page):
- Bonin E, Brehove T, Carlson C, Downing M, Hoeft J, Kalinowski A, Solomon-Bame J, Post P. (2010). Adapting your practice: general recommendations for the care of homeless patients. Nashville: Health Care for the Homeless Clinicians' Network.
- Brehove, T., Joslyn, M., Morrison, S., Strehlow, A. J., and Wismer, B. (2007). Adapting your practice: treatment and recommendations for homeless people with diabetes mellitus. Nashville: Health Care for the Homeless Clinicians’ Network.
- Bloch, G. Primary care interventions into poverty. http://ocfp.on.ca/cme/povertytool (accessed 3 February, 2014).
List three ways in which A.J.’s mobility restrictions can impact his health:
- Difficulty in getting to and from doctor’s appointments to seek care.
- Ability to exercise and maintain a healthy weight, worsening his diabetes and predisposing him to cardiovascular disease and other conditions.
- Safety in the shelter and on the streets. The loss of a limb affects his ability to seek a safer environment or to defend himself. This also lends itself to a stressful living situation, impacting A.J.’s psychological well-being.
As you conduct the physical exam, A.J. comments that his left foot has been painful for the last few days whenever he applies weight to the limb. You examine his foot, noting a shallow, non-purulent ulcer to the heel. The surrounding skin is red, hot and indurated. He denies fever or other constitutional symptoms, but you suspect cellulitis.
You discuss your concerns with A.J. and recommend that he needs antibiotic therapy. What are two important considerations when prescribing this treatment?
You discuss your concerns with A.J. and recommend that he needs antibiotic therapy. What are two important considerations when prescribing this treatment?
- Paying for and obtaining the antibiotic, either oral or intravenous (the latter will require either inpatient or outpatient antibiotic therapy depending on the region in which you practice).
- Close follow-up of his cellulitis, with lower threshold for admission to hospital care. A.J.'s access to proper nutrition, the ability to elevate his leg during the day and access to wound care will impact wound healing. His diabetes makes the chance of progression to more serious infections, such as osteomyelitis, more likely and more rapid to develop.
One week later, you are on your family medicine rotation in the inner city where again, you meet A.J. He managed to not require hospital admission and is slowly improving on antibiotics. You are checking his latest lab results and note that his glycemic control has been poor for several years, with an HbA1c ranging between 10-12%. He has not responded to oral antihyperglycemics and his physician is considering placing him on insulin therapy.
While controlling his serum glucose is a priority, what are three concerns regarding the prescription of insulin?
While controlling his serum glucose is a priority, what are three concerns regarding the prescription of insulin?
- Risk of hypoglycemic episodes due to, for example, access to regular meals. Tight glucose control may not be recommended as a result.
- Lack of access to refrigeration to store insulin.
- If using syringes for insulin injection, these become a target of theft. Pen injectors are recommended if this is a concern.
You decide to go ahead with insulin therapy, but A.J. is concerned that he won't be able to afford the medication.
What about A.J.’s social and health context could help with finding financial aid to help pay for his medications?
What about A.J.’s social and health context could help with finding financial aid to help pay for his medications?
- Living with a physical disability – he may be eligible for tax credits or other financial aid.
- Aboriginal, with status, can pay for drugs and extended health benefits not covered by provincial plans.