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

4. INTRODUCTION

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

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

24. DIABETES MELLITUS

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. *

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

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

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

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

56. THANK YOU!