Narrator: Urgent care medicine is a fast-growing sector in healthcare delivery. Patients like the convenience of the walk-in service and quick treatment. Many find the traditional route of primary care hard to navigate…especially if they are uninsured or under-insured.

Nurse Practitioner: I’ve been out of school for a year now. I love my position as a nurse practitioner at an urgent care clinic. We are just off the Interstate so I see a lot of conditions…you just never know what may come through the door.

***

Nurse Practitioner: I was pulling into the parking lot the other morning and I saw this 18-wheeler parked at the far end of the lot. My first patient that day, surprise! was a trucker, and a patient I had seen a few weeks ago.

Receptionist: Good morning.

Manuel: I need to talk to Beth please.

Receptionist: Okay. Fill out both sides of the paper and bring it back to me. We’ll call you in a few minutes.

***

Narrator: He was a stout man…46 years of age, five-eight, 160 pounds…very pleasant demeanor…

Another voice: Mr. Rodriguez? Hi, please follow me.

Nurse Practitioner Beth: Good morning, Manuel. What brings you back so soon?

Manuel: I’m glad you are here today. I have another rash…same place…

Nurse Practitioner: For how long?

Manuel: About a week...it seems to be getting worse. It’s very itchy, but it doesn’t really hurt.

Nurse Practitioner: He had a similar rash a few weeks ago. Manuel reminded me that we treated the old rash successfully with an over-the-counter antifungal cream. But this new rash was red…and with a foul smell and a thick white substance collecting in the folds of his uncircumcised penis. He had no penile discharge, dysuria, testicular pain, fever or chills. His vital signs were normal. A genitalia exam demonstrated a confluent erythematous rash of the glans of the penis and distal shaft. The diagnoses: Candida balanitis…yeast… So, again, I recommended a topical anti-fungal cream. But this was recurring, so I wondered if there was another underlying cause.

Some background on my patient: Manuel hadn’t received medical care in many years due to his constant travel as a long-haul trucker. He was an independent contractor for a large shipping firm…was responsible for his own health insurance…high deductible. Both things contributed to his avoidance of primary care and a lack of documented medical history. I suggested to him that we perform a blood panel and a few other screening procedures to see if there was an underlying condition which caused his chronic rash.

I also wanted to expand on his history.

Nurse Practitioner: I’d like to know if there may be something I’m missing that could help us figure this out. Well, are you married, kids? What exactly are you doing for work right now?

Manuel: I’m divorced, 10 years now. No kids. I drive a lot. Sometimes I see both coasts the same week.

Nurse Practitioner: Sexual partners?

Manuel: You know, my parents........

Nurse Practitioner: I can assure you nothing you have to tell me will be shared with family unless you give us permission. Have you had any sexual partners since your divorce?

Manuel: Only on the road.

Nurse Practitioner: He didn’t present with symptoms of an STI. But some forms can lay dormant, asymptomatic for years.

Nurse Practitioner: When was the last time you had sex?

Manuel: Last week.

Nurse Practitioner: How often do you have sex and how many partners?

Manuel: Not too often, maybe once a month or so. Usually different partners… guys.

Nurse Practitioner: Are you using condoms?

Manuel: Most of the time, not all the time though.

***

Narrator: According to the Centers for Disease Control, new HIV cases are the highest among gay and bisexual men. Seventy percent of all new HIV infections are found in this group. Both HIV and AIDS are sometimes associated with rashes and persistent infections.

Manuel: Could you also test me for COVID? The guy I was with last week… he thought he might have it.

Nurse Practitioner: Manuel didn’t have any other symptoms of COVID-19, but some patients have reported rashes. Viral infections like COVID, HIV, and the flu tend to have similar and very common symptoms. Skin changes linked to mild or severe COVID-19 include a flat, red rash, usually covered with small bumps, and discolored areas on the digits called COVID toes. Some patients have even reported hives. Manuel also wasn’t reporting respiratory or flu-like symptoms that could indicate COVID or acute HIV, but I ordered screening tests for both—just in case.

***

Nurse Practitioner: While taking Manuel’s medical history, I noticed that he was drinking from a water bottle. In fact, he had finished one bottle, crushed it with a loud crinkle, and was starting to empty a second.

Nurse Practitioner: Are you always this thirsty?

Manuel: I drink a lot of water, a boatload of coffee, and Mountain Dew® Code Red®. The caffeine keeps me awake for the long hauls.

Nurse Practitioner: Based on his powerful thirst, and the recurrent yeast infections, I also ordered a third point-of-care screening test, an HbA1c for diabetes.

***

Nurse Practitioner: First, the good news. Manuel tested negative for both HIV and COVID-19. Neither virus was causing his recurrent rashes. However, his HbA1c which was also performed at the point of care, was 10.4%. We had a diagnosis of diabetes…type 2.

***

Nurse Practitioner: I started him on metformin. Our urgent care facility is vertically integrated, so I referred him to our primary care division. He promised to follow-up with all of his appointments.

I explained to him it was a good thing he was diagnosed early to prevent further complications and hopefully avoid insulin use! We reviewed his diet and I suggested some ideas for healthier meal choices, but I had to admit that it was going to be harder for him to eat healthy when he was on the road all of the time. I noted in his referral to the primary care physician that he may benefit from a dietitian consult because of his job. We also discussed safe sex practices and the importance of using condoms.

My patient left urgent care with a diagnosis and new awareness of viral transmission. He was back on the road again!

Manuel: Thank you. I am glad to know what was wrong with me.

Narrator: Early intervention can prevent the need for insulin use. In the past, truckers who traveled across state lines had to file a Federal Diabetes Exemption if they used insulin. This had a negative impact on their trucking careers and opportunities for long-haul employment. Fortunately, the law was changed in 2018. Now drivers with insulin-treated diabetes have to get a medical examiner’s certificate to prove they are physically fit to operate a commercial vehicle. If we can keep them off insulin using early detection, they won’t have to deal with the hassles of injections and medical certifications. U.S. truckers moved almost 11 billion tons of freight last year.

Narrator: There are common symptoms and scenarios in the urgent care setting where point-of-care screening with HbA1c may assist in the early diagnosis of diabetes: Candida infections, UTIs, enuresis or nocturia, dehydration, acanthosis or truncal obesity, changes in vision, or glucose levels above 140 mg/dL during a random blood panel.

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Don’t miss this just-published article from Jay H. Shubrook, DO; Lindsey E. Fish, MD; and OMG host, Jane Caldwell, PhD—and other extras in our FAST LINK SHOW NOTES.

HbA1c As Screening/Diagnoses for Early or Asymptomatic Diabetes in the Urgent Care Facility
The Journal of Urgent Care Medicine (JUCM)