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.