ENG - Lapsus DM PDF

 

FAMILY MEDICINE FACULTY OF MEDICINE UNIVERSITY OF HASANUDDIN

FAMILY MEDICINE CASE REPORT:  FAMILY MEDICINE APPROACH ON AN ELDERLY PATIENT WITH TYPE 2 DIABETES MELLITUS

Disusun Oleh :

Muthia Raihana Hakim (XC064181069)  Victoria Jane Satya (XC064181068)

Pembimbing :

Dr. dr. Suryani Tawali, MPH

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK DEPARTEMEN IKM / IKK FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN NOVEMBER 2019

 

FAMILY MEDICINE CASE REPORT: FAMILY MEDICINE APPROACH ON AN ELDERLY PATIENT WITH TYPE 2 DIABETES MELLITUS Victoria Jane Satya1*, Muthia R. Hakim1*, Suryani Tawali1* 1) Department of Community Medicine, *Faculty of Medicine University of Hasanuddin, Makassar, Indonesia

 A bs tract:  This case study presents the management of type 2 diabetes mellitus on an elderly patient using a comprehensive and holistic family medicine approach. Interventions are applied on the patient, the family members and the surrounding community, and on multiple aspects (lifestyle, medications and control of disease). With a shift upon perception on the disease, and with the full-support obtained from the family and the community, the patient would be able to increase the endeavors in executing an improved healthy way of living. Thus achieving the ideal management targets. Keyword: type 2 diabetes mellitus, family medicine, elderly patient  

 

INTRODUCTION Diabetes mellitus (DM) is a complex non-communicable disease that is indicated with chronic hyperglycemia due to insulin secretion, action of insulin, or both. The most common form is type 2 DM which is non-insulin dependents diabetes mellitus (NIIDM). Worldwide estimated prevalence of adults with DM has increased from 4.7% in 1980, to 8.5% or 422 million in 2014. A large proportion of the working force is negatively affected in terms of social, functional and also the development of a country. (WHO, 2019) Indonesia has been ranked amongst the top 10 countries to contribute upon DM cases worldwide. Out of 12 million affected patients in 2013, the majority of affected population were 55-64 year-olds (6,3%), followed by 65-74 year-olds (6,0%). Meanwhile, the predilection of the location was in the urban area (10,6%). (Kementerian Kesehatan, 2018)  A local survey recorded as many as 17,843 DM cases in 2015, scoring DM as the third most-common non-communicable disease in the hospitals and the primary health centers in the South Celebes province. (Dinas Kesehatan Sulawesi Selatan, 2016) With a high mortality rate, DM has caused 176,000 deaths every year, marking it as the third most common cause of mortality amongst other diseases. Pathologically, DM poses a higher risk upon cardiovascular disorders, end-stage renal disease, vision loss, amputation and eventually death. Hence there needs to be strict management and monitoring of the blood glucose. (Wardiah et al. 2018) Considering the importance upon the awareness of DM, this case report aims to evaluate the application of family medicine approach, which pivots around the patient and the family, using Mandala of Health and the evidence-based medicine.

 

Case illustration  A 75-year-old 75-year-old male named Mr. AKT was interviewed interviewed upon a home visit conducted by the health attendant from the Primary Health Center Mamajang. Mr. AKT was known to have type-2 diabetes mellitus since 2009 as he had a sudden loss of consciousness due to hyperglycemia then (random blood glucose: 420 mg/dl). Aside from reporting polydipsia and polyuria “from time to time”, the patient did not have any

other complaint regarding his chronic condition. Of note, the patient has been on Glibenclamide (1x50mg) and on a routine checkup for fasting blood glucose and blood pressure at the local apothecary, where an internal specialist practiced at. Sometimes, he also visits the integrated health post within the vicinity. He had a history of alcohol consumption since 40 years ago, but had abstained from drinking till up to date. No history of smoking was found. Mr. AKT denied having hypertension, cardiovascular disorders, allergy and asthma. Similar complaint or disease was not found in the family; one of his sisters had died of an unknown cause of dyspnea. On examination he was generally well, compos mentis with Karnofsky score of 80%. The body mass index was normal at 19.35 with body mass 50 kg and height 160 cm. However, fasting blood glucose records from 9 September and 10 October 2019 were 219 and 142 mg/dl, respectively. (Figure 1 dan 2)

Figure 1. Mr. AKT, a diabetes mellitus patient in Mamajang

Figure 2. Patient regularly visited the local pharmacy for monthly check up

  Born on 30th December 1994, he is the firstborn amongst 5 siblings. Mr. AKT has 8 children. He has been living with his wife (Hj. HDK, 74 years-old) and his daughter, as well as his two grandsons in a house which occupancy was deemed less-worthy (kurang layak huni )).. Situated in the North Kancil street (Mamajang, Makassar), the

 

house has two stories and was 4m x 12m in size with inadequate ventilation (one window on the second floor) hence the humid air inside. In addition there are two bathrooms with a well as the source of water for bath and laundry purposes. Meanwhile, the kitchen was placed in the adjacent room which resembled a storage room. The floor was heavily ingrained with dirt and clothes scattered. (Figure 3 and 4)

Figure 3. House with inadequate ventilation

Figure 4. Interview with patient and the wife

  Since the patient is no longer employed due to his advanced age, the daily life revolves around his home: eating, sleeping, and sometimes helping out his daughter sell beverages at a small stall in the alley across his place. However he regularly visits his children in another province, Gowa, every month. Mr. AKT has a public health insurance Askes, as all the elderly patients in Indonesia should have. Unless he felt extremely unwell, he would not visit the primary health center or the hospital to get treated. Instead, he would buy medicine at the nearest pharmacy. In order to evaluate the health of the patient comprehensively, this study used the Mandala of Health concept. Genogram of Mr. AKT family per 5 th  November 2019 was obtained, though incomplete due to insufficient data, and showed Mr. AKT as a DM patient who lives in a house with his wife and his one daughter, as well as his two grandsons. There was no discovery of DM or other diseases within the first-degree relative. (Figure 5)

 

  Figure 5. Genogram of Mr. AKT family

The functionality of the family was assessed subjectively using Family APGAR score in which the result from the interview suggested that Mr. AKT had full support in terms of adaptation, partnership, growth, affection and resolve upon managing his chronic condition. Thus the outcome was ten out of ten which indicated a highly functional family. (Table 1) Table 1. Screening for family dysfunction using Family APGAR   No

Com Componen ponent/ t/cl clos oseded-end ended ed ques questi tion on Alw lway ays s ((2)Oft 2)Often en (1) (1) Rare Rare (0) (0)

I am satisfied with the advice and support 1 that I receive from my family when something is troubling me

√

2

I am satisfied with the way my family discusses items of comm on interest interest and shares problem-solving with me

√

3

The relationship between me and my family is cordial/friendly

√

4

I amsatisfied with the way my family expresses affection and responds to my feelings such as anger, sorrow and love

√

I am satisfied with the way my family and I 5 are able to resolve our differences in opinionand opinionan d arrive at solutions

√

 

  Holistic diagnosis was determined in 5 aspects. The first aspect suggested a patient with classic DM signs who wished to know the progress of his chronic disease in hopes that it is managed well; the patient realized consuming sugary and carbohydraterich diet would worsen his health, thus he and the family put in efforts in avoiding those in spite of the undying habit of drinking sweet beverages. The second aspect is based on the interview, physical examination and laboratory test results. Thus the clinical diagnosis was identified as type-2 diabetes mellitus (E10-E11). Without a family history of similar complaints or any hereditary diseases, there was no evidence of genetic inheritance in the third aspect; biologically, the patient had normal BMI without any existing risk factors for DM. However the lifestyle from his past whilst he still worked as a labor at the port may have affected his uncontrolled diet with excessive alcohol intake. At the moment, the patient still consumed a non DM-friendly diet due to insufficient education on the disease. Psychologically, the patient was burdened by his wife’s health problems (hypertension and cataract) where the wife heavily depended on him on daily basis. On the fourth aspect, the patient need not worry upon having to spend on the treatment since he had Askes. In terms of social aspect, he had no problem maintaining relationship within the family and within the neighborhood. The fifth aspect indicated the patient functioned normally without disability. (Figure 6)

Figure 6. Mandala of Health of Mr. AKT

 

  Holistic and comprehensive intervention was applied upon the patient, the family and the surrounding community. Education upon the disease itself and the recommended lifestyle were given (eg. increasing the daily activities; selective diet with low calorie, carbohydrate and fat) whilst giving a sense of optimism in order to keep a stable glucose level. The family members were expected to involve the patient in daily activities, give moral support, whilst monitoring the intake of patient’s medication . Discussion Type-2 diabetes mellitus was diagnosed on a 74 years-old Mr. AKT whose blood glucose had been monitored regularly at the local pharmacy. Initially the diagnosis was given considering the age at the onset of longstanding hyperglycemia and thus had been on treatment since 2009. During the oral monotherapy treatment, his blood glucose was mostly stable, suggesting correction upon the beta cell function. (IDI, 2014) Nonetheless the inability to control the diet well, such as consuming sweetened beverages, prevented the patient in achieving better results of the disease management. Thus the recommendation of fibrous carbohydrate intake was suggesested, as found in the fruits. Control upon the frequency and amount of diet intake were also noted in order to prevent weight gain. Balanced diet should be taken to avoid hyperglycemia complications that could injure the nervous system and the cardiovascular system. The family was enlightened on this as well in order to be able to support the patient with appropriate diet. (Wardiah, 2016; Paleeratana, W. 2019) The patient had a relatively limited routine of physical activities. According to the literature, fewer physical activities could decrease the insulin effect at the receptor level which would result in insulin resistence. On the contrary, increased physical activity has been proven to lower the risk of hypertension, overweight, stroke, osteoporosis and cardiovascular diseases. Light exercises that were recommended for elederly patients: arm swings, short steps and light-to-moderate light-to-m oderate aerobic. (Desi, PS. et al, 2013) Hygiene is also of utmost importance for diabetes patients, especially foot hygiene. Screening upon neuropathic disorder, such as loss of sensation and loss of pulse at the lower extremity, should be done during the regular visits. Awareness in foot hygiene could prevent wound formation and eventulally amputation, decreasing the risk of morbidity on the patient. (Nanang, M. et al, 2016) Glibenclamide has been taken orally as a monotherapy by the patient. Classified in the sulfonylurea group, Glibenclamide mainly increases insulin secretion. Unlike Metformin that was most widely used, this sulfonylurea drug had no side effect of dyspepsia and diarrhea, thus was a good choice for this elderly patient who was more likely to be prone towards gastrointestinal disturbances. (Perkeni, 2015) The target achievement of DM is based on the blood glucose, HbA1C and the lipid profile. The routine follow-ups should give: normal BMI (18.5-22.9), blood pressure