Department of Family & Community Medicine Department of Family & Community Medicine Perpetual Succour Hospital Perpetual Succour Hospital “LIFE IS SO SWEET IN DIABETES” DR. LIZA D. MARIPOSQUE 2 ND Year FAMED Resident AUG. 13, 2009 FAMILY CASE PRESENTATION
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Department of Family & Community MedicineDepartment of Family & Community MedicinePerpetual Succour HospitalPerpetual Succour Hospital
“LIFE IS SO SWEET IN
DIABETES”
DR. LIZA D. MARIPOSQUE
2ND Year FAMED ResidentAUG. 13, 2009
FAMILY CASE PRESENTATION
OBJECTIVESOBJECTIVES
General Objective:General Objective:
To discuss the family profile of To discuss the family profile of Bontilao-Duenas Family Bontilao-Duenas Family
To present a case of Diabetes To present a case of Diabetes Mellitus Type 2Mellitus Type 2
Specific Objectives:Specific Objectives:
1.1. To present a patient with Diabetes To present a patient with Diabetes Mellitus Type 2.Mellitus Type 2.
2.2. To briefly discuss the management To briefly discuss the management of DM type 2.of DM type 2.
3.3. To establish the family diagnosis To establish the family diagnosis using family assessment tools.using family assessment tools.
The HouseThe House 120 x 60 sq.m.120 x 60 sq.m. Mixed Construction Mixed Construction
materials materials w/ sari-sari storew/ sari-sari store 1 bedroom1 bedroom 1 CR1 CR Living room & Living room &
Dining roomDining room
Closed drainageClosed drainage Poor ventilationPoor ventilation Water Source: MCW & bottled Water Source: MCW & bottled
Mineral Mineral Water with Water with coverscovers
Toilet: Water-sealed typeToilet: Water-sealed type Garbage Disposal: collectionGarbage Disposal: collection
Living Area & Dining AreaLiving Area & Dining Area
B.D., 51 y.o, female, Filipino, Roman B.D., 51 y.o, female, Filipino, Roman Catholic,a barangay health worker, Catholic,a barangay health worker, from Lahug, Cebu City from Lahug, Cebu City
Chief ComplaintsChief Complaints
Fever, epigastric painFever, epigastric pain
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
Medical Problems:Medical Problems:– HPN x 24 Years – Calcibloc 35mg ODHPN x 24 Years – Calcibloc 35mg OD– DM 2 x 4 years – Glibenclamide 5 mg 1 DM 2 x 4 years – Glibenclamide 5 mg 1
Sought consult and diagnosed Sought consult and diagnosed with Pneumonia. Given with Pneumonia. Given Cefuroxime 500mg 1 tab BID Cefuroxime 500mg 1 tab BID for 1 week.for 1 week.
1 month PTC – admitted at PSH for 3 1 month PTC – admitted at PSH for 3 days.days.
Final diagnosis:Final diagnosis: Community Acquired PneumoniaCommunity Acquired Pneumonia Diabetes Mellitus Type 2Diabetes Mellitus Type 2 Hypertensive Cardiovascular DiseaseHypertensive Cardiovascular Disease
4.4. Co-amoxiclav (Augmentin) 625 mg Co-amoxiclav (Augmentin) 625 mg 1 tab BID after breakfast & supper 1 tab BID after breakfast & supper for 1 week.for 1 week.
3 wks PTC – still with intermittent low 3 wks PTC – still with intermittent low grade grade fever. fever.
- follow-up with AP and - follow-up with AP and givengiven with with Cepodoxime 200mg 1 tab Cepodoxime 200mg 1 tab BID BID for 1 week. Maintenance for 1 week. Maintenance
characterized by hyperglycemia as a characterized by hyperglycemia as a cardinal biochemical feature. cardinal biochemical feature.
– major forms:major forms: Type 1 DMType 1 DM, or , or T1DMT1DM
– Deficiency of insulin secretion due to Deficiency of insulin secretion due to pancreatic β-cell damage. pancreatic β-cell damage.
Type 2 DMType 2 DM, or , or T2DMT2DM– Insulin resistance occurring at the level of Insulin resistance occurring at the level of
skeletal muscle, liver, and adipose tissue, skeletal muscle, liver, and adipose tissue, with various degrees of β-cell impairmentwith various degrees of β-cell impairment
- Most common endocrine-metabolic disorder of - Most common endocrine-metabolic disorder of childhood and adolescence. childhood and adolescence.
-Formerly called insulin-dependent diabetes Formerly called insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes.mellitus (IDDM) or juvenile diabetes.
– Ave. onset in childhood: 7 to 15 yr age. Ave. onset in childhood: 7 to 15 yr age.
– Characterized by low or absent levels of Characterized by low or absent levels of endogenously produced insulin due to autoimmune endogenously produced insulin due to autoimmune destruction of pancreatic islet β cells and destruction of pancreatic islet β cells and dependence on exogenous insulin. dependence on exogenous insulin.
Type 1 DMType 1 DM
- most prevalent in adults.most prevalent in adults.
- Formerly known as adult-onset diabetes - Formerly known as adult-onset diabetes mellitus, mellitus, NIDDMNIDDM, or maturity-onset , or maturity-onset diabetes of the young (diabetes of the young (MODYMODY).).
Morbidity and mortality incidence are Morbidity and mortality incidence are due to acute metabolic due to acute metabolic derangementsderangements
Long-term complications affect small Long-term complications affect small and large vessels. and large vessels.
The acute clinical manifestations are The acute clinical manifestations are due to hypoinsulinemic due to hypoinsulinemic hyperglycemic ketoacidosis. hyperglycemic ketoacidosis.
ScreeningScreening
FPGFPG– widely use as a screening test for type 2 DMwidely use as a screening test for type 2 DM– recommended: recommended: 1.1. A large number of individuals who meet the A large number of individuals who meet the
current criteria for DM are asymptomatic and current criteria for DM are asymptomatic and unaware that they have the disorder.unaware that they have the disorder.
2.2. Epidemiologic studies suggest that type 2 DM Epidemiologic studies suggest that type 2 DM may be present for up to a decade before may be present for up to a decade before diagnosis.diagnosis.
3.3. 50% of individuals with type 2 DM have one or 50% of individuals with type 2 DM have one or more diabetes-specific complications at the more diabetes-specific complications at the time of their diagnosistime of their diagnosis
4.4. Treatment of type 2 DM may favorably alter Treatment of type 2 DM may favorably alter the natural history of DM. the natural history of DM.
ADA Screening Recommendations:ADA Screening Recommendations:
>45 years Old, every 3 years >45 years Old, every 3 years an earlier age if they are overweight an earlier age if they are overweight
[body mass index (BMI) > 25 kg/m2] [body mass index (BMI) > 25 kg/m2] Have one additional risk factor for Have one additional risk factor for
diabetesdiabetes
Risk Factors for Type 2 Diabetes Mellitus
Family history of diabetes (i.e., parent or sibling with type 2 diabetes)
American, Asian American, Pacific Islander) Previously identified IFG or IGT History of GDM or delivery of baby >4 kg (>9 lb) Hypertension (blood pressure ≥ 140/90 mmHg) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) Polycystic ovary syndrome or acanthosis nigricans History of vascular disease
Diagnostic Criteria for Impaired Glucose Tolerance and Diabetes Mellitus
Symptoms[*] of DM plus random plasma glucose ≥200 mg/dL (11.1 mmol/L)
or
2-hr plasma glucose during the OGTT but ≤140 mg/dL
Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L)
<200 mg/dL (11.1 mmol/L) or
2-hr plasma glucose during the OGTT ≥200 mg/dL
From Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1999;20(Suppl 1): S5.
* Symptoms include polyuria, polydipsia, and unexplained weight loss with glucosuria and ketonuria. OGTT, oral glucose tolerance test.
Overall Principles For Long-Term Overall Principles For Long-Term Treatment:Treatment:(1)(1) Eliminate symptoms related to hyperglycemia.Eliminate symptoms related to hyperglycemia.(2)(2) Reduce or eliminate the long-term microvascular Reduce or eliminate the long-term microvascular
and macrovascular complications of DM.and macrovascular complications of DM.(3)(3) Allow the patient to achieve as normal a lifestyle Allow the patient to achieve as normal a lifestyle
as possible. as possible.
Target level of glycemic control for each patient.Target level of glycemic control for each patient. Provide educational and pharmacologic Provide educational and pharmacologic
resources.resources. Monitor/treat DM-related complications. Monitor/treat DM-related complications. Symptoms of diabetes usually resolve when the Symptoms of diabetes usually resolve when the
plasma glucose is <11.1 mmol/L (200 mg/dL)plasma glucose is <11.1 mmol/L (200 mg/dL)
BONTILAO-DUENAS FAMILY GENOGRAMBONTILAO-DUENAS FAMILY GENOGRAM
Susan40
I
II
III
Arlene39
FAMILY PROFILEFAMILY PROFILE
BONTILAO-DUENAS FAMILYBONTILAO-DUENAS FAMILY
Smilkstein’s Cycle of Family FunctionSmilkstein’s Cycle of Family Function
STREESFUL LIFE EVENTS:Pneumonia & poorly controlled sugar
CRISIS:Inadequate family income
EXTRA-FAMILIAL RESOURCES:Free medicinesFinancial Assistance from the Capitol & Brgy. LahugHelp from co-workers
work
FAMILY IN EQUILIBRIUM
DISEQUILIBRIUM
Impact of IllnessImpact of Illness
Stage I – Onset of IllnessStage I – Onset of Illness
Stage II – Reaction to Diagnosis (Impact Stage II – Reaction to Diagnosis (Impact phase)phase)
Stage III – Major Therapeutic effortsStage III – Major Therapeutic efforts
Stage IV – Early Adjustment to Outcome Stage IV – Early Adjustment to Outcome (Recovery)(Recovery)
Stage V – Adjustment to the Permanency of Stage V – Adjustment to the Permanency of thethe
OutcomeOutcome
Almost always(2)
Some of the Time (1)
Hardly Ever(0)
ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me.
PARTNERSHIP: I am satisfied with the way my family talks on things with me and shares problems with me.
GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities or directions
AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotion such as anger, sorrow and love
RESOLVE: I am satisfied with the way my family and I share time together
FAMILY APGARBernadette: Index Patient
APGAR SCORE: 9 (Highly Functional)
Almost always(2)
Some of the Time
(1)
Hardly Ever
(0)
ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me.
PARTNERSHIP: I am satisfied with the way my family talks on things with me and shares problems with me.
GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities or directions
AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotion such as anger, sorrow and love
RESOLVE: I am satisfied with the way my family and I share time together
FAMILY APGAREdgardo: Husband
APGAR SCORE: 9 (Highly Functional)
SCREEMSCREEM ResourceResource Weakness
Social The family participates in socialactivities such as family
reunions &fiesta celebrations. They also
haveGood relationships with theirneighbors, friends and co-
workers.No known enemies.
Cultural They have embraced Filipino values
and apply these in their everyday
life (i.e. respecting elders).
Religious
The family attends mass everySunday in St. Therese ParishChurch. They are aware of
religiousevents in the local community
They do not participate in any religious organization.
SCREEMSCREEM ResourceResource WeaknessWeakness
Economic Edgardo is working as “Brgy. Tanod” and Editha as a Brgy Health Worker. The monthly income of both is enough to provide the basic necessities of the family.
Financial problem arises only if they will support the expenses of their grandchildren and if someone will get sick.
Educational Edgardo and Editha are highschool graduates hence, making them capable of solving problems rationally and they able to send their children to college.
Medical When medical problems arises, the family can easily access their private physician to seek consultation
Blood sugar of Editha is poorly controlled and she had difficulty to comply laboratory work-up.
samples of medicines.samples of medicines.• Regular follow-up check-up with the Family Regular follow-up check-up with the Family
Physician.Physician.• Monitoring of the BP and blood sugar.Monitoring of the BP and blood sugar.• For rpt CXR and sputum exam with AFB.For rpt CXR and sputum exam with AFB.• Proper budgeting of the family monthly income.Proper budgeting of the family monthly income.• Referral to PCSO and Diabetic Clinic.Referral to PCSO and Diabetic Clinic.
medication.medication. Have regular monitoring of the BP.Have regular monitoring of the BP. For lipid panel and FBS screening.For lipid panel and FBS screening.
To the Family:To the Family:
Help their mother to buy some Help their mother to buy some maintenance medication.maintenance medication.
Encourage their mother to diet and Encourage their mother to diet and do some exercise every morning.do some exercise every morning.
Encourage to save electricity by Encourage to save electricity by turning-off the aircon & lights if not in turning-off the aircon & lights if not in use.use.
Advise to be careful in their diet.Advise to be careful in their diet.
FAMILY DIAGNOSISFAMILY DIAGNOSIS Bontilao-Duenas Family Bontilao-Duenas Family
The stage of family cycle: Family in The stage of family cycle: Family in later yearslater years
Stage III – Major Therapeutic effortsStage III – Major Therapeutic efforts APGAR Assessment: Highly functionalAPGAR Assessment: Highly functional Smilkstein Family Cycle: family is in Smilkstein Family Cycle: family is in
equilibrium.equilibrium. Evaluation by SCREEM showed Evaluation by SCREEM showed
resources and strength of Social, resources and strength of Social, Cultural, Religion, Education, Cultural, Religion, Education, Economic and Medical; however Economic and Medical; however some weakness noted in terms of some weakness noted in terms of economic and medical.economic and medical.