This is the first Case for Comments which has been formally assessed. Each
comment has been broken down into components, which have been independently
marked by assessors on a scale from +2 (highly appropriate) to -2 (highly
inappropriate). The mean score for each component is given in the summary.
To assess the value of your own comment, simply add the score for each of
its components. The independently assessed score for my own comment is
given as 'par for the course'.
I will be keeping a record of the comment scores for each CME-registered
participant, and sending them a summary of their own performance relative
to the group as a whole at regular intervals. In the I hope unlikely event
of a dispute between myself and a participant on the scoring of an
individual comment, I am afraid to say that my decision will be final. This
is not because I think I'm better than anyone else, it is simply that I
won't have time!
> > Subject: Case 30 for comment
> > Date: 06 June 1998 10:52
> >
> > A 57 year old man, seeing his Community Physician. Clinical information
> > 'Non-insulin-dependent diabetes mellitus. Fasting blood sample'.
> >
> > Sodium: 140 mmol/L
> > Potassium: 4.5 mmol/L
> > Urea: 8.9 mmol/L (2.8 - 7.0)
> > Creatinine: 133 umol/L (62 - 133)
> > Albumin: 39 g/L
> > Calcium: 2.42 mmol/L
> > Uric acid: 485 umol/L
> > Cholesterol 6.9 mmol/L (3.0 - 6.5)
> > Triglyceride: 2.2 mmol/L (0.4 - 1.8)
> > HDL-cholesterol: 1.1 mmol/L (0.8 - 1.8)
> > LDL-cholesterol: 4.8 mmol/L (<4.5 )
> > Fructosamine: 373 umol/L (205 - 285)
> This Case attracted 32 participants.
> 3 would not usually comment in the context of their own hospital [-0.4].
> 1 would contact the Community Physician to discuss the Case [+1.0].
>
> 6 commented poor short term glycaemic control [+1.8]
> 6 commented sub-optimal/ moderate/ mediocre short term glycaemic control
[+1.4]
> 3 commented 'poorly controlled DM [+1.6]
>
> 5 commented mild renal impairment [+1.6]
> 3 commented renal impairment [+1.0]
> 1 commented incipient renal failure [-0.4]
>
> 6 commented hyperlipidaemia (4 of these adding mild and/or secondary)
[+0.4]
> 6 suggested increased CV risk [+0.8]
>
> 1 suggested the possibility of Reaven's syndrome [-0.2]
>
> 6 suggested diabetic control could be improved [+1.2]
> 13 suggested reviewing risk factors and appropriate therapy (3 adding 'in
line with local guidelines) [+1.2];
> 4 suggested action to lower cholesterol or lipids [+0.2]
> 3 mentioned weight reduction if appropriate [+0.4]
>
> 8 suggested measurement of albumin/ creatinine ratio [+1.4]
> 5 suggested measuring glycated haemoglobin [+0.6]
> 3 would suggest creatinine clearance [+0.6]
> 2 would suggest checking blood pressure [-0.2]
> 2 would monitor albumin/ creatinine ratio [+1.2]
> 1 would monitor renal function [+1.0]
> 1 would review patient's daily blood glucose record [0]
>
> 1 would query fasting status [+0.2]
> 2 would check fasting glucose [-0.4]
> 1 each would check
> proteinuria [+0.4]
> urea [-0.4]
> haematology [-0.6]
> I'm never too sure how best to deal with lipids on a diabetic subject,
> particularly one who is not well controlled (my assumption is that they
> will improve with better glycaemic control).
> I checked previous results on this patient, and a year earlier, both urea
> and creatinine had been significantly lower than these values.
> My comment was
> 'Moderate to poor recent glycaemic control.
> Urea and creatinine suggest a deterioration in renal function.
> Worth measuring microalbumin?'
Comment score +4.8
Best wishes and happy counting!
Gordon Challand
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