Amir Khan

Age: 51 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

Take a systematic head-to-toe approach:

  • Ask about vision changes, including any blurry vision.
  • Ask if they’ve noticed increased thirst, frequent urination, or feeling hungrier than usual.
  • Ask about chest pain or shortness of breath, especially if there are cardiovascular concerns.
  • Ask about any tingling or numbness in the legs or feet, or if they’ve noticed sores or wounds on their feet that are slow to heal.
  • Ask about unintentional weight loss or gain.
  • Review medication compliance — if they’ve missed doses or stopped taking anything, explore why.
  • Explore psychosocial factors: smoking or alcohol use, dietary habits and physical activity, home environment and support system, occupation — especially if related to driving 
  • Give a working diagnosis of poorly controlled type 2 diabetes based on symptoms and test results.

Example of explanation to patient​

Amir, your recent blood test shows that your diabetes is not well-controlled. Before we move forward, can I check—do you understand why your blood sugar might be high? It’s important that we keep it within a healthy range.

I completely understand that managing blood sugar can be difficult, but it’s crucial for your overall health. When diabetes isn’t well-managed, it can lead to long-term complications, including problems with your eyes, kidneys, heart, and nerves. These complications can significantly affect your quality of life. The good news is that with the right steps, you can reduce these risks and maintain a healthy, active lifestyle. Would you like us to go through some of the options we have to help you achieve better control?

Since you’ve mentioned you’d prefer not to use insulin, one oral option we can consider is a tablet called empagliflozin. It’s effective in lowering blood sugar and can also have benefits for the heart and kidneys. However, like all medications, it can have side effects. These may include an increased risk of urine infections or genital thrush. In rare cases, it can cause a more serious infection called Fournier’s gangrene, though this is extremely uncommon, and most people do very well on the medication.

Also, I know you’re concerned about informing the DVLA. You mentioned that this was one of the reasons you were hesitant about starting insulin. It’s important to know that, as a Group 2 driver, you are legally required to inform the DVLA about your diabetes diagnosis, even if you’re not using insulin. This is essential for your own safety and the safety of others on the road

Management

  • Request urine ACR, lipid profile, and calculate Q-risk to fully assess cardiovascular and kidney health.

Note: Chronic kidney disease (CKD) can occur even when EGFR is within the normal range, especially in people with uncontrolled type 2 diabetes. That’s why we check the ACR (albumin-to-creatinine ratio) even when kidney function appears normal.

Consider the below medication options to improve glycaemic control:

  • SGLT2 inhibitors (e.g., Empagliflozin) — especially useful in diabetes with cardiovascular or renal risk.
  • DPP-4 inhibitors (e.g., Linagliptin or Sitagliptin) — can be added if tolerated.

Note: Avoid Dapagliflozin if the patient is on pioglitazone, as this combination is not licensed.

  • GLP-1 medications—such as oral semaglutide or subcutaneous injections like Mounjaro (tirzepatide)—are available options for this patient.  However, they are not typically considered next line treatments in this particular setting and would require specialist input, particularly in the case of semaglutide   
  • Advise the patient that you will inform the diabetes team about the proposed medication changes and co-ordinate shared care if necessary.
  • Emphasise the importance of lifestyle measures: weight loss, balanced diet (reducing processed carbs and sugary foods), regular physical activity
  • Offer routine vaccinations: Pneumococcal, influenza, and COVID-19
  • Arrange annual diabetic screening, including retinal eye check and foot examination
  • Advise on driving regulations: Since the patient is a Group 2 driver (HGV/lorry), they are legally required to notify the DVLA about their diabetes — whether they are on insulin or not— to ensure fitness to drive and review licensing conditions.
  • Follow up in 3 months to review blood sugar control and response to treatment.
  • Safety net about DKA symptoms (feeling very sick, stomach pain, breathlessness, or fruity-smelling breath) and side effects of new medication (Empagliflozin)

Learning point from this station: ​

Effective diabetes management involves more than just lowering blood sugar — it requires a patient-centred and tailored approach, especially in complex cases. This case highlights the importance of understanding next steps in treatment escalation when Hba1c remains uncontrolled despite current therapy.

When a patient is reluctant to use insulin — as in this case, due to a fear of needles and being a Group 2 HGV driver (where insulin use can impact driving eligibility) — it’s vital to explore non-insulin alternatives. Insulin may not be suitable for such patients because of the risk of hypoglycaemia and occupational restrictions.

Options below can be considered.

  • SGLT2 inhibitors (e.g., empagliflozin) — useful for blood sugar control and cardiovascular protection,
  • DPP-4 inhibitors, and
  • GLP-1 receptor agonists (e.g., semaglutide) — which aid in weight loss and glycaemic control,

NICE recommends GLP-1 receptor agonists particularly if: Triple therapy fails or isn’t tolerated or contraindicated and they meet below criteria 

  • BMI ≥35 (or lower if insulin poses occupational concerns), or
  • Weight loss would benefit other obesity-related conditions.

Finally, reinforcing lifestyle modifications; including diet, physical activity, and weight loss, remains a cornerstone of care, and must always be addressed alongside pharmacological strategies.