revise family case presentation final
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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
ECONOMIC PROFILEECONOMIC PROFILE
Total Monthly Total Monthly IncomeIncome
12, 000 php12, 000 php PERCENT PERCENT ALLOCATIONALLOCATION
Total MonthlyTotal MonthlyExpenses:Expenses: Food:Food: Electricity: Electricity: Water: Water: Medicine: Medicine: Miscellaneous:Miscellaneous:
5,600 – 9, 5,600 – 9, 600600
2,0002,000500 - 4,000500 - 4,0006006001,500 - 2,0001,500 - 2,000>1,000>1,000
47 – 80% 47 – 80%
16.7%16.7%4.2 – 39%4.2 – 39%5%5%13- 17%13- 17%9%9%
Savings Savings 2, 4002, 400 20%20%
INDEX CASE PROFILEINDEX CASE PROFILE
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
tab tab BID & Metformin BID & Metformin 500mg 1 500mg 1 tab TIDtab TID
Non-alcoholic, non-smokerNon-alcoholic, non-smoker No allergiesNo allergies HFD: HPN, DM 2HFD: HPN, DM 2
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
Previous Hospitalization: Previous Hospitalization:
2007 – DM Type 2 (PSH)2007 – DM Type 2 (PSH)
2005 – Pneumonia (PSH)2005 – Pneumonia (PSH)
HISTORY OF PRESENT HISTORY OF PRESENT ILLNESSILLNESS
6 mos. PTC – intermittent fever temporarily 6 mos. PTC – intermittent fever temporarily relieved with Paracetamol and relieved with Paracetamol and Alaxan.Alaxan.
2 mos. PTC – persistent high-grade fever.2 mos. PTC – persistent high-grade fever.
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
Home meds:Home meds:
1.1. Metformin 500 mg 1 tab BID.Metformin 500 mg 1 tab BID.
2.2. Glibenclamide 5 mg 1 tab BID 30 Glibenclamide 5 mg 1 tab BID 30 min. before breakfast or supper.min. before breakfast or supper.
3.3. Nefidepine (Calcibloc) 30 mg 1 tab Nefidepine (Calcibloc) 30 mg 1 tab OD.OD.
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
meds are continued.meds are continued.
- Laboratory requested.- Laboratory requested.
LABORATORY RESULTSLABORATORY RESULTS
URINALYSISURINALYSIS 5/5/095/5/09 5/28/095/28/09 8/5/098/5/09
Color & transparencyColor & transparency Yellow, Yellow, clearclear
Yellow, Yellow, clearclear
Yellow, Yellow, clearclear
GlucoseGlucose NEGNEG NEGNEG NEGNEG
ProteinProtein NEGNEG NEGNEG NEGNEG
pHpH 55 66 55
Urine Ketone, Nitrite, Urine Ketone, Nitrite, UrobilinogenUrobilinogen
NEGNEG NEGNEG NEGNEG
RBC/hpfRBC/hpf 0-10-1 0-20-2 0-10-1
WBC/hpfWBC/hpf 0-10-1 0-20-2 0-30-3
Epithelial cellsEpithelial cells FEWFEW RARERARE EMDEMD
Mucus ThreadsMucus Threads ERER RARERARE EMDEMD
BacteriaBacteria ERER RARERARE MODRMODR
CBCCBC N.V.N.V. 5/21/05/21/099
5/28/05/28/099
8/5/08/5/099
WBCWBC 4-11.304-11.30 12.612.6 15.5015.50 9.49.4
NeutrophilsNeutrophils 47-80%47-80% 7171 7171 6969
LymphocytesLymphocytes 13-40%13-40% 1919 2020 1919
MonocytesMonocytes 2-11%2-11% 77 77 99
EosinophilEosinophil 0-5%0-5% 22 22 33
HbHb 12-1612-16 14.114.1 14.314.3 13.513.5
HctHct 36-46%36-46% 4141 40.640.6 4040
MCVMCV 80-10080-100 8686 82.482.4 8888
plateletplatelet 140-140-440440
332332 330330 278278
LABORATORY RESULTSLABORATORY RESULTS
5/5/095/5/09 5/28/05/28/099
6/7/06/7/099
6/20/06/20/099
RBSRBS 65.66 65.66 mg/dlmg/dl
196 196 mg/dlmg/dl
265 265 mg/dlmg/dl
397 397 mg/dlmg/dl
HBA1HBA1cc
5.50 5.50 %%
4.8%4.8% 5.6%5.6%
TSH TSH
7/14/097/14/092.650 2.650
(n.v.0.27-4.20)(n.v.0.27-4.20)
uIU/mLuIU/mL
LABORATORY RESULTSLABORATORY RESULTS
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Conscious, coherent, not in Conscious, coherent, not in respiratory distress.respiratory distress.
BP: 140/80 mmHgBP: 140/80 mmHg T: 37T: 3700CC HR: 70 HR: 70 bpmbpm
RR: 18 cpmRR: 18 cpm Wt: 87 kgWt: 87 kg Ht: 5’1”Ht: 5’1”
Waistline circumference: 46 inchesWaistline circumference: 46 inches
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Skin:Skin: Dark, (+) frickles and warts, warm Dark, (+) frickles and warts, warmHEENT:HEENT: Anicteric sclerae, pinkish palpebral Anicteric sclerae, pinkish palpebral
conjunctivae, conjunctivae, (-) TPC (-) TPCNeckNeck: : No lymphadenopathiesNo lymphadenopathiesC/L:C/L: Equal chest expansion, No chest retractions, Equal chest expansion, No chest retractions,
Clear Clear breath soundsbreath sounds, , No ralesNo ralesCVS:CVS: Distinct heart sounds, normal rate & regular Distinct heart sounds, normal rate & regular
rhythm, rhythm, no murmurno murmurAbd:Abd: Flabby, normoactive bowel sounds, soft, non- Flabby, normoactive bowel sounds, soft, non-
tender, tender, no masses palpated, no no masses palpated, no hepatomegalyhepatomegaly
Ext:Ext: No edema, strong pulses No edema, strong pulsesCNS:CNS: Within normal limits Within normal limits
FINAL DIAGNOSISFINAL DIAGNOSIS
Community Acquired Pneumonia Community Acquired Pneumonia – resolvingresolving
Diabetes Mellitus Type 2Diabetes Mellitus Type 2– poorly controlledpoorly controlled
Hypertensive Cardiovascular DiseaseHypertensive Cardiovascular Disease
Current Medications:Current Medications:
Glimeperide 2.5 mg + Metformin Glimeperide 2.5 mg + Metformin 500mg (Glucovance) 1 tab BID500mg (Glucovance) 1 tab BID
Pioglitazone 30 mg 1 tab dailyPioglitazone 30 mg 1 tab daily Nifedepine (Calcibloc) 30 mg 1 tab Nifedepine (Calcibloc) 30 mg 1 tab
OD.OD. Ranitidine 150mg 1 tab BID.Ranitidine 150mg 1 tab BID.
Diabetes MellitusDiabetes Mellitus– common, chronic, metabolic syndrome common, chronic, metabolic syndrome
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).).
- Characterized by:- Characterized by:– impaired insulin secretionimpaired insulin secretion– insulin resistanceinsulin resistance– excessive hepatic glucose productionexcessive hepatic glucose production– abnormal fat metabolismabnormal fat metabolism
Type 2 DMType 2 DM
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)
Obesity (BMI ≥ 25 kg/m2) 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
Diagnostic Criteria for Impaired Glucose Tolerance and Diabetes Mellitus
IMPAIRED GLUCOSE TOLERANCE (IGT) DIABETES MELLITUS (DM)
Fasting glucose 110–125 mg/dL (6.1–7.0 mmol/L)
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)
Treatment Goals for Adults with Diabetesa
Index Goal
Glycemic controlb
A1C <7.0c
Preprandial capillary plasma glucose 5.0–7.2 mmol/L (90–130 mg/dL)
Peak postprandial capillary plasma glucose <10.0 mmol/L (<180 mg/dL)d
Blood pressure <130/80e
Lipidsf
Low-density lipoprotein <2.6 mmol/L (<100 mg/dL)
High-density lipoprotein >1.1 mmol/L (>40 mg/dL)g
Triglycerides <1.7 mmol/L (<150 mg/dL)
Glucose-Lowering Therapies for Type 2 Diabetes
MOA Examples Advantages Disadvantages C.I.or Relative C.I.
Oral
Biguanides Hepatic glucose production, weight loss, glucose, utilization, insulin resistance
Metformin Weight loss Lactic acidosis, diarrhea, nausea
Serum creatinine >1.5 mg/dL (men) >1.4 mg/dL (women), CHF, acidosis
a –Glucosidase inhibitors
Glucose absorption
Acarbose, Miglitol
Reduce postprandial glycemia
GI flatulence, liver function tests
Renal/liver disease
Dipeptidyl peptidase IV inhibitors
Prolong endogenous GLP-1 action
Sitagliptin Does not cause hypoglycemia
Reduce dose with renal
MOA ADVANTAGES DISADVANTAGES C.I.
Insulin secretagogues— sulfonylureas
Insulin secretion
Lower FBS Hypoglycemia, weight gain
Renal or liver disease
Insulin secretagogues—nonsulfonylureas
Insulin secretion
Short onset of action, lowers PPG
Hypoglycemia Renal or liver disease
Thiazolidinediones Insulin resistance, glucose utilization
Lower insulin requirements
Peripheral edema, CHF, weight gain, fractures, macular edema; rosiglitazone may increase risk of MI
CHF, liver disease
Parenteral MOA ADVANTAGES
DISADVANTAGES
C.I.
Insulin Glucose utilization and other anabolic actions
Known safety profile
Injection, weight gain, hypoglycemia
GLP-1 agonist
Insulin, Glucagon, slow gastric emptying
Weight loss Injection, nausea, risk of hypoglycemia with insulin secretagogues
Renal disease, agents that also slow GI motility
Amylin agonist - Pramlintide
Slow gastric emptying, Glucagon
Reduce PPG, weight loss
Injection, nausea, risk of hypoglycemia with insulin
Agents that also slow GI motility
Nutritional Recommendations for Adults with Diabetes
Fat
20–35% of total caloric intake
Saturated fat < 7% of total calories
<200 mg/day of dietary cholesterol
Two or more servings of fish/week provide @ -3 polyunsaturated fatty acids
Minimal trans fat consumption
Carbohydrate
45–65% of total caloric intake (low-carbohydrate diets are not recommended)
Amount and type of carbohydrate importantb
Sucrose-containing foods may be consumed with adjustments in insulin dose
Protein
10–35% of total caloric intake (high-protein diets are not recommended)
Other components
Fiber-containing foods may reduce postprandial glucose excursions
Nonnutrient sweeteners
BONTILAO-DUENAS BONTILAO-DUENAS FAMILYFAMILY
Unilaterally extended FamilyUnilaterally extended Family Externally PatriarchalExternally Patriarchal Internally MatriarchalInternally Matriarchal 2 members2 members
FAMILY CIRCLEFAMILY CIRCLE
Editha’s point-of-view Edgardo’s point-of-view
Esmeralda, 64 Manuel, 56Florentino, 60 Isabelo, 57
Manuel JR, 53
Editha51
Criselda48
Dante36
Amelita34
Edgardo50
Joey48
Danny46
Marites44
Lailane42
Clinton30
Raquel26
Rosanna24
1986
LEGEND: DM BA Liver Cirrhosis Infected GB
HPN Goiter
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.
INTERVENTIONSINTERVENTIONSPatientPatient
• EducationEducation• Lifestyle modification.Lifestyle modification.• Diet & exercise. Diet & exercise. • Continue taking maintenance and giving free Continue taking maintenance and giving free
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.
To the Husband:To the Husband:
Education & lifestyle modificationEducation & lifestyle modification Diet & exerciseDiet & exercise Continue taking antihypertensive Continue taking antihypertensive
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
• Unilaterally Extended typeUnilaterally Extended type• Middle classMiddle class• Father – breadwinnerFather – breadwinner• Mother – breadwinner & primary Mother – breadwinner & primary
caregivercaregiver
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.