Numb Feet, an Unfelt Sore, and a Glucose of 68
Priya, 47, has had type 2 diabetes for 12 years and her last HbA1c was 9.1%. She books a 90-minute relaxation massage and mentions, 'my feet feel numb and tingly, and there's a sore on my left heel I can't really feel.' She takes insulin and metformin, drove herself, and ate lunch about an hour ago. She checks her phone: her glucose is 68 mg/dL, and she says she feels 'a little shaky.' She wants extra work on her feet and lower legs because of swelling.
1. She is on your table with a shaky feeling and a reading of 68 mg/dL. What has to happen before the session can start?
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Nothing else happens first - 68 mg/dL with symptoms is hypoglycemia, and massage is not started until it is corrected.
- Give a fast-acting carbohydrate (roughly 15 g: juice, glucose tabs, regular soda), have her stay seated, and recheck in about 15 minutes. Repeat until she is above 70 mg/dL and her symptoms have resolved.
- If she becomes confused, cannot swallow safely, or loses consciousness, that is an emergency call, not a snack.
- If she drove herself, do not send her out immediately after a symptomatic low. Let her stabilize, eat something with protein and carbohydrate, and confirm she feels normal before she leaves.
There is a second, less obvious reason to pause: massage itself can lower blood glucose, and she took insulin before a 90-minute session. Even after correction, the plan should shrink - a shorter session, glucose within reach on the counter, and a recheck partway through. The 90 minutes she booked is not the priority; a client who does not go hypoglycemic on your table is.
2. Now the heel sore and the numb feet. How do these change technique and scope?
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They change both, in opposite directions.
The sore is a local contraindication. Inspect it before touching it - if it is open, draining, or surrounded by red, warm, or darkened skin, work the whole heel and ankle region around it, not over it, and do not apply lotion near an open wound. Poorly controlled diabetes (HbA1c 9.1%) plus reduced sensation plus a wound she cannot feel is a combination that heals slowly and infects easily. That belongs with her physician or podiatrist, and saying so is part of your job, not an overreach.
The numbness changes pressure, not just location. Neuropathy means she cannot accurately tell you when pressure is too much, so a pressure level she would normally report as 'too deep' may go unregistered until tissue is damaged. Use broad contact instead of point pressure, stay on the lighter side even though she asked for extra work, inspect the skin visually and by touch every few minutes, and skip anything thermal - she cannot reliably sense heat.
With a 9.1% HbA1c and an open heel, reasonable judgment is to spend little or no time on the feet today and redirect the session to the back, shoulders, and hips.
3. Write the chart note essentials and list the findings that would make you end the session early.
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Chart essentials: the glucose value she reported, her symptoms in her own words, what you gave her, the recheck value and time, and confirmation she was stable before starting. Describe the heel wound by size, location, appearance, and whether it was open or intact. Record the pressure level used and that you checked skin condition during the session. Record the referral - recommend PCP or podiatrist review of the wound and of the HbA1c - in the plan, along with her stated intent to follow up.
End early if: glucose drops again or shakiness, sweating, or confusion returns; the heel or surrounding skin becomes redder, warmer, or starts draining; skin under your hands shows unusual pallor, redness, or marking that does not fade; she reports dizziness, nausea, or a headache; or she reports numbness spreading or new burning in a limb. In each case stop, reposition her, correct what you can within scope, and refer.
The pattern the exam is testing: a client can ask for something (deep foot work, a full 90 minutes) that the clinical picture makes a poor idea, and your job is to modify and explain rather than comply or cancel.