Revise Family Case Presentation Final

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  • D is for Diet I is for Insulin, human or pig it doesn't matter A is forAmbulance to take you to hospital when you not feeling well B is for Bruises for after you have blood taken from you E is for Eating wronly which we shouldn't but we do T is for Treats that are very hard to find E is for Energy which diabetes need a lot of S is for Sweets which we shouldn't have CC: Claire Page
  • During the Martial Law in year 1977, Bernadette known to many as “Editha” , 20 years old at that time, a high school student at UV, Cebu City when she met her husband Edgardo. Edgardo a 19 year old, a conductor of a pasengers jeep called “VICTOR” got attracted to Editha her regular passenger. At first, they went out together as “Barkada”. Few months after, when the driver of the jeepney died, since the wake was just in front of editha’ s house they got the chance to see each other more often. They become more closer and love blossomed with each other. A year after, Edgardo and Editha decided to live together. A year later,she gave birth to Clinton in 1979. In 1982, Raquel was born and in 1984, then came Rosanna, thru C/S at Cebu Maternity Hospital and then she consented to had bilateral tubal ligation. From then on… as years have passed, the sexy body of Editha was gone. She loves to eat chocolate, all sorts of sweets, drinks cola almost every after a meal.. Fourteen years later… she was diagnosed with Hypertension, she was compliant with her medications. Ten years later, because of uncontrolled, overly sweet diet, Editha was diagnosed with Diabetes Mellitus. 4 yrs after, her dilemma started when she stopped her exercise and diet plans hence she cannot refuse the call of sweet foods everyday. D is for Diet I is for Insulin, human or pig it doesn't matter A is for Ambulance to take you to hospital when you not feeling well B is for Bruises for after you have blood taken from you E is for Eating wrongly which we shouldn't but we do T is for Treats that are very hard to find E is for Energy which diabetes need a lot of S is for Sweets which we shouldn't have CC: Claire Page
  • Diabetes Mellitus: Introduction Diabetes mellitus (DM) refers to a group of common, chronic metabolic disorders that share the phenotype of hyperglycemia as a cardinal biochemical feature. The worldwide prevalence of DM has risen dramatically over the past two decades, from an estimated 30 million cases in 1985 to 177 million in 2000. Based on current trends, >360 million individuals will have diabetes by the year 2030. While in Asia & Australia, in year 2000- 82.7M number of people who had Diabetes and it will increase in year 2030 to 190.5M. The projected prevalence of DM in persons 35-64 years is 3-5%. Diabetes was the fifth leading cause of death worldwide and was responsible for almost 3 million deaths annually (1.7–5.2% of deaths worldwide). In the United States, DM is the leading cause of end-stage renal disease (ESRD), nontraumatic lower extremity amputations, and adult blindness. It also predisposes to cardiovascular diseases. With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality for the foreseeable future. That is why FBS screening is important hence, early detection of DM lead us to prevention of complications.
  • Several distinct types of DM exist and are caused by a complex interaction of genetics and environmental factors. Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production. The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
  • Two features of the current classification of DM diverge from previous classifications. First, the terms insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) are obsolete. Since many individuals with type 2 DM eventually require insulin treatment for control of glycemia. A second difference is that age is not a criterion in the classification system. Although type 1 DM most commonly develops before the age of 30, an autoimmune beta cell destructive process can develop at any age. It is estimated that between 5 and 10% of individuals who develop DM after age 30 have type 1 DM. Type 2 DM is characterized by impaired insulin secretion, insulin resistance, excessive hepatic glucose production, and abnormal fat metabolism. Obesity, particularly visceral or central (as evidenced by the hip-waist ratio), is very common in type 2 DM. In the early stages of the disorder, glucose tolerance remains near-normal, despite insulin resistance, because the pancreatic beta cells compensate by increasing insulin output (Fig. 338-7). As insulin resistance and compensatory hyperinsulinemia progress, the pancreatic islets in certain individuals are unable to sustain the hyperinsulinemic state. IGT, characterized by elevations in postprandial glucose, then develops. A further decline in insulin secretion and an increase in hepatic glucose production lead to overt diabetes with fasting hyperglycemia. Ultimately, beta cell failure may ensue.
  • Type 2 DM is preceded by a period of abnormal glucose homeostasis classified as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). The National Diabetes Data Group and World Health Organization have issued diagnostic criteria for DM. Individuals with IFG and/or IGT, recently designated pre-diabetes by the American Diabetes Association (ADA), are at substantial risk for developing type 2 DM (25–40% risk over the next 5 years) and have an increased risk of cardiovascular disease.
  • a As recommended by the ADA; Goals should be developed for each patient (see text). Goals may be different for certain patient populations. b A1C is primary goal. c While the ADA recommends an A1C < 7.0% in general, in the individual patient it recommends an ". . . A1C as close to normal (<6.0%) as possible without significant hypoglycemia. . . ." Normal range for A1C—4.0–6.0 (DCCT-based assay). d One-two hours after beginning of a meal. e In patients with reduced GFR and macroalbuminuria, the goal is <125/75. f In decreasing order of priority. g For women, some suggest a goal that is 0.25 mmol/L (10 mg/dL) higher. Source: Adapted from American Diabetes Association, 2007.
  • L: Raquel 26 y.o. ff by her daughter Athena Grace, 9y.o studying at USP-Elem. School (Asthmatic) Rosanna 24y.o- daughter ff Editha is Dannica Rachelle 5 y.o studying at USP Elem. School. Clinton 30y.o, beside him is his daughter Wenona Lyn 10 y.o studying at Lahug Elem. School.
  • Husband: Edgardo, 50 years old. Brgy. Tanod at Brgy. Lahug, Cebu City Known HPN, poor compliant of Neobloc Diet & Exercise
  • changes in lifestyle (diet and exercise for 30 min/day five times/week) in individuals with IGT prevented or delayed the development of type 2 DM by 58%.

Transcript

  • 1. Department of Family & Community Medicine Perpetual Succour Hospital “ LIFE IS SO SWEET IN DIABETES” DR. LIZA D. MARIPOSQUE 2 ND Year FAMED Resident AUG. 13, 2009 FAMILY CASE PRESENTATION
  • 2. OBJECTIVES
    • General Objective:
    • To discuss the family profile of Bontilao-Duenas Family
    • To present a case of Diabetes Mellitus Type 2
  • 3.
    • Specific Objectives:
    • To present a patient with Diabetes Mellitus Type 2.
    • To briefly discuss the management of DM type 2.
    • To establish the family diagnosis using family assessment tools.
  • 4. INTRODUCTION
  • 5. The House
    • 120 x 60 sq.m.
    • Mixed Construction materials
    • w/ sari-sari store
    • 1 bedroom
    • 1 CR
    • Living room & Dining room
  • 6.
    • Closed drainage
    • Poor ventilation
    • Water Source: MCW & bottled Mineral Water with covers
    • Toilet: Water-sealed type
    • Garbage Disposal: collection
  • 7. Living Area & Dining Area
  • 8. ECONOMIC PROFILE 20% 2, 400 Savings 47 – 80% 16.7% 4.2 – 39% 5% 13- 17% 9% 5,600 – 9, 600 2,000 500 - 4,000 600 1,500 - 2,000 >1,000 Total Monthly Expenses: Food: Electricity: Water: Medicine: Miscellaneous: PERCENT ALLOCATION 12, 000 php Total Monthly Income
  • 9. INDEX CASE PROFILE
    • B.D., 51 y.o, female, Filipino, Roman Catholic,a barangay health worker, from Lahug, Cebu City
  • 10. Chief Complaints
    • Fever, epigastric pain
  • 11.
    • PAST MEDICAL HISTORY
    • Medical Problems:
      • HPN x 24 Years – Calcibloc 35mg OD
      • DM 2 x 4 years – Glibenclamide 5 mg 1 tab BID & Metformin 500mg 1 tab TID
    • Non-alcoholic, non-smoker
    • No allergies
    • HFD: HPN, DM 2
  • 12.
    • PAST MEDICAL HISTORY
    • Previous Hospitalization:
    • 2007 – DM Type 2 (PSH)
    • 2005 – Pneumonia (PSH)
  • 13. HISTORY OF PRESENT ILLNESS
      • 6 mos. PTC – intermittent fever temporarily relieved with Paracetamol and Alaxan.
      • 2 mos. PTC – persistent high-grade fever.
      • Sought consult and diagnosed with Pneumonia. Given Cefuroxime 500mg 1 tab BID for 1 week.
  • 14.
    • 1 month PTC – admitted at PSH for 3 days.
    • Final diagnosis:
    • Community Acquired Pneumonia
    • Diabetes Mellitus Type 2
    • Hypertensive Cardiovascular Disease
  • 15.
    • Home meds:
    • Metformin 500 mg 1 tab BID.
    • Glibenclamide 5 mg 1 tab BID 30 min. before breakfast or supper.
    • Nefidepine (Calcibloc) 30 mg 1 tab OD.
    • Co-amoxiclav (Augmentin) 625 mg 1 tab BID after breakfast & supper for 1 week.
  • 16.
    • 3 wks PTC – still with intermittent low grade fever.
    • - follow-up with AP and given with Cepodoxime 200mg 1 tab BID for 1 week. Maintenance meds are continued.
    • - Laboratory requested.
  • 17. LABORATORY RESULTS EMD RARE ER Mucus Threads 0-3 0-2 0-1 WBC/hpf 0-1 0-2 0-1 RBC/hpf 5 6 5 pH NEG NEG NEG Protein NEG NEG NEG Glucose Yellow, clear Yellow, clear Yellow, clear Color & transparency RARE RARE NEG 5/28/09 MODR ER Bacteria EMD FEW Epithelial cells NEG NEG Urine Ketone, Nitrite, Urobilinogen 8/5/09 5/5/09 URINALYSIS
  • 18. LABORATORY RESULTS 278 330 332 140-440 platelet 88 82.4 86 80-100 MCV 40 40.6 41 36-46% Hct 13.5 14.3 14.1 12-16 Hb 19 20 19 13-40% Lymphocytes 69 71 71 47-80% Neutrophils 9.4 15.50 12.6 4-11.30 WBC 0-5% 2-11% N.V. 3 2 2 Eosinophil 9 7 7 Monocytes 8/5/09 5/28/09 5/21/09 CBC
  • 19. LABORATORY RESULTS 265 mg/dl 6/7/09 4.8% 196 mg/dl 5/28/09 5.6% 5.50 % HBA1c 397 mg/dl 65.66 mg/dl RBS 6/20/09 5/5/09 2.650 (n.v.0.27-4.20) uIU/mL TSH 7/14/09
  • 20. PHYSICAL EXAMINATION
    • Conscious, coherent, not in respiratory distress.
      • BP: 140/80 mmHg T: 37 0 C HR: 70 bpm
      • RR: 18 cpm Wt: 87 kg Ht: 5’1”
      • Waistline circumference: 46 inches
  • 21.
    • PHYSICAL EXAMINATION
    • Skin: Dark, (+) frickles and warts, warm
    • HEENT: Anicteric sclerae, pinkish palpebral conjunctivae, (-) TPC
    • Neck : No lymphadenopathies
    • C/L: Equal chest expansion, No chest retractions, Clear breath sounds , No rales
    • CVS: Distinct heart sounds, normal rate & regular rhythm, no murmur
    • Abd: Flabby, normoactive bowel sounds, soft, non-tender, no masses palpated, no hepatomegaly
    • Ext: No edema, strong pulses
    • CNS: Within normal limits
  • 22. FINAL DIAGNOSIS
    • Community Acquired Pneumonia
      • resolving
    • Diabetes Mellitus Type 2
      • poorly controlled
    • Hypertensive Cardiovascular Disease
  • 23. Current Medications:
    • Glimeperide 2.5 mg + Metformin 500mg (Glucovance) 1 tab BID
    • Pioglitazone 30 mg 1 tab daily
    • Nifedepine (Calcibloc) 30 mg 1 tab OD.
    • Ranitidine 150mg 1 tab BID.
  • 24. DIABETES MELLITUS
  • 25.
    • Diabetes Mellitus
      • common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature.
      • major forms:
        • Type 1 DM , or T1DM
          • Deficiency of insulin secretion due to pancreatic β-cell damage.
        • Type 2 DM , or T2DM
          • Insulin resistance occurring at the level of skeletal muscle, liver, and adipose tissue, with various degrees of β-cell impairment
  • 26.
    • - Most common endocrine-metabolic disorder of childhood and adolescence.
      • Formerly called insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes.
      • Ave. onset in childhood: 7 to 15 yr age.
      • Characterized by low or absent levels of endogenously produced insulin due to autoimmune destruction of pancreatic islet β cells and dependence on exogenous insulin.
    Type 1 DM
  • 27.
    • most prevalent in adults.
    • - Formerly known as adult-onset diabetes mellitus, NIDDM , or maturity-onset diabetes of the young ( MODY ).
    • - Characterized by:
      • impaired insulin secretion
      • insulin resistance
      • excessive hepatic glucose production
      • abnormal fat metabolism
    Type 2 DM
  • 28.
    • Morbidity and mortality incidence are due to acute metabolic derangements
    • Long-term complications affect small and large vessels.
    • The acute clinical manifestations are due to hypoinsulinemic hyperglycemic ketoacidosis.
  • 29. Screening
    • FPG
      • widely use as a screening test for type 2 DM
      • recommended:
      • A large number of individuals who meet the current criteria for DM are asymptomatic and unaware that they have the disorder.
      • Epidemiologic studies suggest that type 2 DM may be present for up to a decade before diagnosis.
      • 50% of individuals with type 2 DM have one or more diabetes-specific complications at the time of their diagnosis
      • Treatment of type 2 DM may favorably alter the natural history of DM.
  • 30. ADA Screening Recommendations:
    • >45 years Old, every 3 years
    • an earlier age if they are overweight [body mass index (BMI) > 25 kg/m2]
    • Have one additional risk factor for diabetes
  • 31. Risk Factors for Type 2 Diabetes Mellitus
      • Family history of diabetes (i.e., parent or sibling with type 2 diabetes)
      • Obesity (BMI ≥ 25 kg/m 2 )
      • Habitual physical inactivity
      • Race/ethnicity (e.g., African American, Latino, Native 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
  • 32.   Diagnostic Criteria for Impaired Glucose Tolerance and Diabetes Mellitus From Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1999;20(Suppl 1): S5. 2-hr plasma glucose during the OGTT ≥200 mg/dL   or <200 mg/dL (11.1 mmol/L) Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L) 2-hr plasma glucose during the OGTT but ≤140 mg/dL or   Symptoms [*] of DM plus random plasma glucose ≥200 mg/dL (11.1 mmol/L) Fasting glucose 110–125 mg/dL (6.1–7.0 mmol/L) DIABETES MELLITUS (DM) IMPAIRED GLUCOSE TOLERANCE (IGT) Symptoms include polyuria, polydipsia, and unexplained weight loss with glucosuria and ketonuria. OGTT, oral glucose tolerance test. *
  • 33. Overall Principles For Long-Term Treatment:
    • Eliminate symptoms related to hyperglycemia.
    • Reduce or eliminate the long-term microvascular and macrovascular complications of DM.
    • Allow the patient to achieve as normal a lifestyle as possible.
    • Target level of glycemic control for each patient.
    • Provide educational and pharmacologic resources.
    • Monitor/treat DM-related complications.
    • Symptoms of diabetes usually resolve when the plasma glucose is <11.1 mmol/L (200 mg/dL)
  • 34. Treatment Goals for Adults with Diabetes a <1.7 mmol/L (<150 mg/dL)    Triglycerides >1.1 mmol/L (>40 mg/dL) g    High-density lipoprotein <2.6 mmol/L (<100 mg/dL)    Low-density lipoprotein   Lipids f <130/80 e Blood pressure <10.0 mmol/L (<180 mg/dL) d      Peak postprandial capillary plasma glucose 5.0–7.2 mmol/L (90–130 mg/dL)    Preprandial capillary plasma glucose <7.0 c    A1C   Glycemic control b Goal Index
  • 35. Glucose-Lowering Therapies for Type 2 Diabetes Reduce dose with renal   Does not cause hypoglycemia Sitagliptin Prolong endogenous GLP-1 action Dipeptidyl peptidase IV inhibitors Renal/liver disease GI flatulence, liver function tests Reduce postprandial glycemia Acarbose, Miglitol Glucose absorption a –Glucosidase inhibitors Serum creatinine >1.5 mg/dL (men) >1.4 mg/dL (women), CHF, acidosis Lactic acidosis, diarrhea, nausea Weight loss Metformin Hepatic glucose production, weight loss, glucose, utilization, insulin resistance Biguanides           Oral   C.I. or Relative C.I. Disadvantages Advantages Examples MOA  
  • 36. C.I. DISADVANTAGES ADVANTAGES MOA CHF, liver disease Peripheral edema, CHF, weight gain, fractures, macular edema; rosiglitazone may increase risk of MI Lower insulin requirements Insulin resistance, glucose utilization Thiazolidinediones Renal or liver disease Hypoglycemia Short onset of action, lowers PPG Insulin secretion Insulin secretagogues—nonsulfonylureas Renal or liver disease Hypoglycemia, weight gain Lower FBS Insulin secretion Insulin secretagogues— sulfonylureas
  • 37. Agents that also slow GI motility Injection, nausea, risk of hypoglycemia with insulin Reduce PPG, weight loss Slow gastric emptying, Glucagon Amylin agonist - Pramlintide   Renal disease, agents that also slow GI motility Injection, nausea, risk of hypoglycemia with insulin secretagogues Weight loss Insulin,       Glucagon, slow gastric emptying    GLP-1 agonist   Injection, weight gain, hypoglycemia Known safety profile Glucose utilization and other anabolic actions    Insulin   C.I.   DISADVANTAGES   ADVANTAGES   MOA Parenteral  
  • 38. Nutritional Recommendations for Adults with Diabetes    Nonnutrient sweeteners    Fiber-containing foods may reduce postprandial glucose excursions Other components    10–35% of total caloric intake (high-protein diets are not recommended) Protein    Sucrose-containing foods may be consumed with adjustments in insulin dose    Amount and type of carbohydrate important b    45–65% of total caloric intake (low-carbohydrate diets are not recommended) Carbohydrate    Minimal trans fat consumption    Two or more servings of fish/week provide @ -3 polyunsaturated fatty acids    <200 mg/day of dietary cholesterol    Saturated fat < 7% of total calories    20–35% of total caloric intake Fat
  • 39. Family Assessment Tools
  • 40. BONTILAO-DUENAS FAMILY
    • Unilaterally extended Family
    • Externally Patriarchal
    • Internally Matriarchal
    • 2 members
  • 41. FAMILY CIRCLE Editha’s point-of-view Edgardo’s point-of-view
  • 42. Esmeralda, 64 Manuel, 56 Florentino, 60 Isabelo, 57 Manuel JR, 53 Editha 51 Criselda 48 Dante 36 Amelita 34 Edgardo 50 Joey 48 Danny 46 Marites 44 Lailane 42 Clinton 30 Raquel 26 Rosanna 24 1986 LEGEND: DM BA Liver Cirrhosis Infected GB HPN Goiter BONTILAO-DUENAS FAMILY GENOGRAM Susan 40 I II III Arlene 39
  • 43. FAMILY PROFILE BONTILAO-DUENAS FAMILY
  • 44.  
  • 45. Smilkstein’s Cycle of Family Function STREESFUL LIFE EVENTS: Pneumonia & poorly controlled sugar CRISIS: Inadequate family income EXTRA-FAMILIAL RESOURCES: Free medicines Financial Assistance from the Capitol & Brgy. Lahug Help from co-workers work ADAPTATION FAMILY IN EQUILIBRIUM DISEQUILIBRIUM
  • 46. Impact of Illness
      • Stage I – Onset of Illness
      • Stage II – Reaction to Diagnosis (Impact phase)
      • Stage III – Major Therapeutic efforts
      • Stage IV – Early Adjustment to Outcome (Recovery)
      • Stage V – Adjustment to the Permanency of the
      • Outcome
  • 47. FAMILY APGAR Bernadette: Index Patient APGAR SCORE: 9 (Highly Functional) RESOLVE: I am satisfied with the way my family and I share time together AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotion such as anger, sorrow and love GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities or directions PARTNERSHIP: I am satisfied with the way my family talks on things with me and shares problems with me. ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me. Hardly Ever (0) Some of the Time (1) Almost always (2)
  • 48. FAMILY APGAR Edgardo: Husband APGAR SCORE: 9 (Highly Functional) RESOLVE: I am satisfied with the way my family and I share time together AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotion such as anger, sorrow and love GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities or directions PARTNERSHIP: I am satisfied with the way my family talks on things with me and shares problems with me. ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me. Hardly Ever (0) Some of the Time (1) Almost always (2)
  • 49. The family attends mass every Sunday in St. Therese Parish Church. They are aware of religious events in the local community They have embraced Filipino values and apply these in their everyday life (i.e. respecting elders). The family participates in social activities such as family reunions & fiesta celebrations. They also have Good relationships with their neighbors, friends and co-workers. No known enemies. Resource They do not participate in any religious organization. Religious Cultural Social Weakness SCREEM
  • 50. When medical problems arises, the family can easily access their private physician to seek consultation Edgardo and Editha are highschool graduates hence, making them capable of solving problems rationally and they able to send their children to college. 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. Resource Weakness SCREEM Blood sugar of Editha is poorly controlled and she had difficulty to comply laboratory work-up. Medical Educational Financial problem arises only if they will support the expenses of their grandchildren and if someone will get sick. Economic
  • 51. INTERVENTIONS
    • Patient
      • Education
      • Lifestyle modification.
      • Diet & exercise.
      • Continue taking maintenance and giving free samples of medicines.
      • Regular follow-up check-up with the Family Physician.
      • Monitoring of the BP and blood sugar.
      • For rpt CXR and sputum exam with AFB.
      • Proper budgeting of the family monthly income.
      • Referral to PCSO and Diabetic Clinic.
  • 52. To the Husband:
    • Education & lifestyle modification
    • Diet & exercise
    • Continue taking antihypertensive medication.
    • Have regular monitoring of the BP.
    • For lipid panel and FBS screening.
  • 53. To the Family:
    • Help their mother to buy some maintenance medication.
    • Encourage their mother to diet and do some exercise every morning.
    • Encourage to save electricity by turning-off the aircon & lights if not in use.
    • Advise to be careful in their diet.
  • 54. FAMILY DIAGNOSIS
    • Bontilao-Duenas Family
      • Unilaterally Extended type
      • Middle class
      • Father – breadwinner
      • Mother – breadwinner & primary caregiver
    • The stage of family cycle: Family in later years
  • 55.
    • Stage III – Major Therapeutic efforts
    • APGAR Assessment: Highly functional
    • Smilkstein Family Cycle: family is in equilibrium.
    • Evaluation by SCREEM showed resources and strength of Social, Cultural, Religion, Education, Economic and Medical; however some weakness noted in terms of economic and medical.
  • 56. THANK YOU!