CONTENTS SECTION TOPIC ACKNOWLEDGEMENT A B SUMMARY OF INDEX PATIENT PAGE 2 4

FAMILY & COMMUNITY 14 PERSPECTIVE & PREVENTIVE CARE OF INDEX PATIENT MANAGEMENT OF INDEX 39 PATIENT CRITICAL REVIEW OF INDEX PATIENT 57

C D E F

FINAL FOLLOW-UP VISIT 62 OF INDEX PATIENT GROUPED DISCUSSION & 64 GROUPED DATA

ACKNOWLEDGMENT Firstly, I would like to take this opportunity to express my gratitude and appreciation to Mr A. Rahman and his family for their willingness in participating in our Community & Family Case Study project over the period of two years. They have been extremely helpful and co-operative in sharing information and details about the familys health issues in general. We have also developed a strong rapport and friendship with Mr A. Rahman and his family. This was also an opportunity for my partner and I to explore the perspective of clinical practice in the community setting. I would also like to thank my CFCS tutors, Prof Hematram Yadav and Dr Nurjahan Ibrahim for their continuous support throughout our case follow-up. They offered much insight and constructive criticism in improving the care of our index patient and his family. We have also learnt a great deal from the personal clinical experiences that they have shared with us. The Clinical Skills Unit (CSU) nurses from the Clinical School, Seremban campus have also played an instrumental role in assisting and guiding Khine and I in the various theme visits, loans of clinical equipments and in conducting home visits. Their dedication in helping us is very much appreciated. Last but not least, I would like to extend my appreciation to my partner, Mr Benjamin Liong Chee Seng who has been nothing short of an excellent teamplayer and colleague in conducting our CFCS project. We have developed an effective working relationship and gained a lot of knowledge gained from each other.

PERSONAL DETAILS OF INDEX PATIENT

Name of patient : Mr A. Rahman Bin Mansur Age Gender Religion Ethnicity Marital Status Occupation Address : 58 years old : Male : Islam : Malay : Married with 4 children : Retired headmaster : 9332, Jalan Kekwa 6, Taman Guru Melayu, Senawang, 70540 Seremban Tel No Problem : 019-3644052/06-6770887 : Diabetes Mellitus Type 2 for 20 years with retinopathy, nephropathy and pheripheral neuropathy
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Section A : SUMMARY OF INDEX PATIENT

PERSONAL DETAILS
4

Mr A. Rahman, a 58 years old, married, Malay, retired headmaster, staying in Senawang CHIEF COMPLAINT He was admitted in Tuanku Jaafar Hospital in 1st of September 2009 for diabetic foot ulcer. HISTORY OF PRESENTING ILLNESS One week prior to the admission, his daughter found a staple stucked on the sole of his left foot. She self-removed it and he did not seek for the treatment since the bleeding was very minimal. However, on the next day, he developed continuous, high grade fever. He then was brought to a private GP and given medication. One week later, he found out that his left foot was red, painful and swollen. He also noticed that the wound caused by the staple was not healing very well with minimal purulent discharge. He was then being admitted in Tuanku Jaafar Hospital for 22 days in view of his current problem. During that admission, the doctor in Tuanku Jaafar hospital started him with insulin actrapid, taken 4 times daily, 15 minutes before each meal. The doctor also found out that his BP was always high during that admission. So, he was started with Perindopril and aspirin. He did not complaint any breathlessness, chest pain and palpitation. His micturition was normal. No hematuria, no frothy urine, no cloudy urine and no sediment in the urine. He did not complaint any weakness of the limb. However, he did complaint blurring of vision in his right eye and numbness sensation over his both lower limb up to the level of ankle. His bowel output was normal. There was no recent changes in his weight and appetite. He did not complain any sign and symptoms of hyperglycemia as well as hypoglycaemia. PAST MEDICAL HISTORY He was diagnosed with Type 2 Diabetes Mellitus for the past 20 years in a private GP (Penawar Clinic) when he complaint of lethargy, polydipsia and nocturia.
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Random Blood Glucosee during that time was about 15mmol/L. He was started with Glibenclamide (Daonil). He went for follow-up there every 2 weeks. In 2000, he was diagnosed with cataract and glaucoma for both of his eyes at KPJ after he complained of blurring of vision for both eyes. Operation was done on her left eye in 2007. In 2002, he was diagnosed with hypercholesterolemia and was started with Lovastatin. In the end of year 2007, he was admitted in KPJ for 9 days due to left foot swollen after returned from performing Umrah. In 2008, he came to see a private GP because of redness, swelling on his left foot up to the level below knee. The GP found fungal infection in interdigitalis space. He claimed that he used wet shoes during gardening on that week. He had few admission of hypoglycaemic attack previously especially during his sleep time, after he injected his pre bed insulin. He knew how to recognise the symptoms and how to recover from it, by taking glucose or biscuits. At the age of 20, he mentioned that he developed scaly skin almost for one year. He seek treatment from traditional healer and the condition get better. He has allergy to dust and certain type of food such as Belacan. He usually develops sinusitis when exposed to dust. CURRENT MEDICATION Diabetes : T.Metformin 500mg BD, S/C Actrapid 14 unit before meal QID Hypertension : T.Perindopril 8mg OD, T.Aspirin 75mg OD Hypercholestrolemia : Lovastatin 20mg ON FAMILY HISTORY His father, 80 years old man, has bronchial asthma. His mother died at the age of 60 due to liver problem. He has 7 siblings and he is the second child. His siblings has bronchial asthma, hypertension, diabetes mellitus and psoriasis. SOCIAL HISTORY
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He has history of smoking for 19 years. Currently, he already stops smoking. He does not consume any alcohol beverages. He likes gardening. Once a week, he will do gardening at his orchard. He did regular exercise every day for 20-30 minutes before his previous admission. He claimed that he eats healthy and balanced diet since he was diagnosed with Type 2 Diabetes Mellitus. He did not has any financial difficulty since he has his own pension.

PHYSICAL EXAMINATION General He is alert, conscious and co-operative. He is not dehydrated or in pale or jaundice. He uses walking stick to walk. His left foot was bandaged.
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Vital sign

BP: 124/74mmHg, Pulse : 105bpm, regular, good volume, no radio-radial delay, Temp : 37 C, Respiratory rate : 18 bpm 7.3mmol/L 79kg 160cm 30.8 87cm No pallor, no icterus. There is corneal archus both eyes. There is xanthelasma below his right eye. Unremarkable

RBS Weight Height BMI Waist circumference Eyes and face Cardiovascular, respiratory and gastrointestinal system Musculoskeletal system Central Nervous System Cranial Nerve Sensory

Unremarkable Normal power, tone and reflex Normal Absent of proprioception sensation on both lower limb Reduce sensation on both feet up to the level of knee

RELEVANT LABORATORY FINDINGS (2009-from one of his admission in private hospital) 1. LIPIDS PROFILE Total Cholestrol Triglycerides 5.3 1.75 High Slightly high
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HDL LDL Total Cholesterol/HDL

1.17 3.33 4.5

Normal High

2. LIVER FUNCTION TEST Total Protein Albumin Globulin Alb/Glob ALP Total Bilirubin AST ALT 73 36 37 99 12 16 33 Normal Normal Normal Normal Normal Normal Normal Normal

3. RENAL PROFILE/BUSE Na K Cloride Urea Creatinine Uric acid Ca eGFR 4. URINE FEME Protein Glucose Ketone Leucocyte 5. FULL BLOOD COUNT Hg PCV 12.6 0.39 Slightly low Slightly low
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131 5 94 7 110 0.41 2.34 60

Slightly low Normal Slightly low Normal Normal Normal Normal Stage 2 CRF

Trace ++ Nil Nil

MCV MCH MCHC WCC Platelet

90 29 326 19.8 319

Normal Normal Normal High Normal

DIAGNOSIS Based on the history, physical findings and investigations done on him, Mr A. Rahman has already developed all of microvascular complications of Type 2 Diabetes mellitus which is peripheral neuropathy, retinopathy and nephropathy. Diagnosis : Type 2 Diabetes Mellitus with retinopathy, nephropathy and peripheral neuropathy
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PROGNOSIS Since Mr Abdul Rahman already has all the microvascular complication, the only aim is to slower the progression of the disease in term of micro and macrovascular complication. The key to halt further deterioration of the illness is determined by the control of several parameters including the long-term blood glucose control, optimisation of blood pressure and serum lipids along with gradual weight loss. If this is achieved, associated micro- and macro-vascular complications can be prevented and slowered down. His previous admission was due to diabetic foot. So, it is important for him to prevent further injury to his foot since he already has peripheral neuropathy. So, following his discharge from diabetic foot, it is important for him to take care of his foot from any injury or fungal infection but at the same time maintain his exercise regime to prevent complications such as contracture or weight gain. SUMMARY OF MEDICAL AND HEALTH NEEDS OF THE PATIENTS Mr A. Rahman, 58 years old, Malay gentleman, known case of hypertension, hypercholesterolemia and Type 2 Diabetes Mellitus with neuropathy, nephropathy and retinopathy should be managed thoroughly in term of medical and non-medical treatment. Multi disciplinary team such as dietician, ophthalmologist, psychiatrist may be involved in order to ensure that successful treatment is achieved. Since the nature of the disease itself is progressing, the aim of the treatment is to maintain the glucose level at normal level but at the same time to avoid hypoglycemia. Therefore, all the complications arise from his condition may be delayed. Mr A. Rahman should be adequately educated about his current problem, the nature of his current problem and other complications that may be arose from his current problem. Therefore, he will understand better and subsequently can take part in his own management and non-compliance to the treatment will not be a problem anymore if he understands the nature of his disease very well. Involvement of his family members may help him to follow the management that already planned to him especially in lifestyle modification. Support from family members may ease the burdens he felt due to his current problem. This is because,
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some patients may feel hopeless when they are prescribed with so many medications and they may become depressed. Besides compliance to medication, Mr A. Rahman also should be emphasized about the need of lifestyle modification in term of exercise, diet, cessation of smoking and foot care. All the community resources surround him such as Diabetes Association should be revealed to him. He can get a lot of information about his current problem through this association. Besides that, he can share his problem with other person who has the same problem with him, so information can be shared in between patient. Therefore, he can utilize them at maximally. Summary : 1. Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia and Obesity Optimum control of the various parameters (blood glucose, HbA1c, blood pressure, serum lipids, waist circumference) to attain as closely to target goals should be aimed for. This can be achieved by concordance and compliance to the treatment regimen, therapeutic lifestyle changes such as dietary modification and increased physical activity. However, Mr Balakrishnan has physical restrictions following the amputation. Nevertheless, simple muscle stretching exercises should be encouraged. Improve comprehension of the underlying disease process. Aggressive diabetic foot care should be advocated and reinforced.

2. Disorders of the Eye

Cataract: o Regular monitoring of the affected eye should be carried out and
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corrective surgery can be performed when deemed suitable with good control of his underlying diseases.
o

Diabetic Retinopathy: Periodical screening and early detection should be performed to ensure early intervention and assuring the best outcomes.

3. Mental Well-being Patients with chronic illnesses such as hypertension and disabilities such as amputees are commonly at a higher risk than the general population to be affected by psychological problems. The odds are even higher for Mr A Rahman as he has several medical problems further affecting his health and psychosocial functions. Therefore, it is also important to screen and detect individuals with these problems early and commence the appropriate management plans.

Section B:
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Family & Community Perspective & Preventive Care of Index Patient

Theme 1:
14

FAMILY STRUCTURE, LIFE CYCLE & ENVIRONMENT

FAMILY GENOGRAM OF MR A. RAHMAN

80 ASTHMA

60 LIVER DIESEASE

MR RAHMAN 58 DM TYPE 2 55 HPT HPT 34 74 5 HYPERCHOLESTROLEMIA TYPE 3 DM A 2

80 HPT STROKE 29 46 ASTHM ASTHM A A

75

15

52

50 31 PSORIASI S

48

2 44

MR RAHMAN,S WIFE 48 HPT DECEASED DECEASED MALE FEMALE 27 DM TYPE FEMALE 2 MALE

FAMILY GENOGRAM My CFCS patient, Mr A. Rahman who was a retired headmaster is diagnosed with Type 2 Diabetes Mellitus, hypertension and hypercholesterolemia. His father has asthma and his mother passed away at the age of 60 years old due to liver disease.

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He married to Mrs Shamsiah, who currently has hypertension and type 2 diabetes mellitus. His father-in-law has hypertension and mild stroke. His motherin-law is generally healthy. He has 7 siblings. His eldest brother died at the age of 4 years old because of congenital problem. He is the second child. The third sibling is now 55 years old. He has type 2 diabetes mellitus and hypertension. The fourth sibling who is a 52 year-old woman is generally healthy. The fifth sibling, 52 years old, is diagnosed with psoriasis since 2 years ago. The sixth sibling who is 48 years old is generally healthy without any known disease. The seventh sibling who is 46 year old has asthma. And his last sibling, who is 44 year old is generally healthy. Mr A. Rahman has 4 children. His first child is Adeline, 34 year-old female. She is a housewife with no history of chronic illness. The second child is Azdalila, 31 year old female, teacher. She has right ovarian cyst. She had undergone 2 cystectomy. The third child is Amir Azhhan, a 29 year-old man. He is an engineer and he has asthma. The last child is Amir Affendi, a 27 year old, technician. He is generally healthy with no chronic disease. He also has 4 grandchildren. All of them are healthy. Based on Mr A. Rahman genogram, it can be concluded that he has strong family history of type 2 diabetes mellitus, hypertension and asthma. Family history of psoariasis also should take into consideration since one of his siblings has been diagnosed with psoariasis. HOME ENVIRONMENT Mr A. Rahman lives in a brick, single storey, and semi-detached house with 60 x 100 square feet. He stays with his wife, Mrs Shamsiah, his first daughter and her husband and his first three grandchildren. The house consists of one living hall, one dining hall, 5 bedrooms, 4 bathrooms, and a wet and dry kitchen. He and his wife sleep in a master bedroom with attached bathroom. His daughter and her family sleep in the other rooms. The house is well kept tidy and
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clean. The furniture is well arranged. The floor is clean and not slippery. So, this reduces the risk of home accident. The compound area is clean. There is lots of flowers since he likes to do gardening. The electrical supply is good. There are rarely episode of electrical black out and water supply cut. However, the water that is supplied to his house is muddy. So, he needs to fix a water filter. Every 3 days, the rubbish will be collected by the authority. Every year, there will be few cases of dengue. Fogging is done every once a week in his area. There is no problem with pest around his area since every once in four monthly, the villagers will held Gotong-Royong to celan all the housing area. The only worry is the presence of wild monkey from forest nearby his housing area. They like to search foods from the dustbin outside the house. This always ends up with foul smelling. PLAN OF MR A RAHMANS HOUSE VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV DRY KITCHEN VVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
BEDROOM 4 WITH ATTACHED BATHROOM WET KITCHEN

DINING HALL BEDROOM 5 WITH ATTACHED BATHROOM

BEDROOM 3

BEDROOM 2 WITH ATTACHED NEIGHBOURHOOD BATHROOM

LIVING HALL

Majority of his neighbour are from Malay family. he has a good relationship with his neighbour since there are lot of his neighbours come to visit him. He is MASTER quit friendlyBEDROOM WITH to his neighbour. FRONT DOOR
ATTACHED BATHROOM 18

Every 4 monthly, the villagers will held Gotong-Royong to clean the housing area. There are also patrolmen that consists of the villagers itself to patrol the housing area during night time since there is a lot of robbery cases in that area. The health facility is not a major issue in his housing area. There are more than 5 private GP near his housing area. The nearest government health clinic is about 10 minutes drive from his house. Other public facilities such as police station, post office, shops and restaurant can be found easily nearby his house.

Theme 2 :
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ILLNESS BEHAVIOUR, SELF CARE, COMPLEMENTARY MEDICINE AND CULTURAL ASPECT OF HEALTH CARE
ILLNESS BEHAVIOUR Generally, when one of family member get sick and the condition is not so severe enough, Mr A. Rahman and his family tend to buy medication from any pharmacy. For instance, for fever, they usually take panadol that they bought over the counter. If the condition getting worst or does not subside within the day, they usually seek the treatment from nearby GP.
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For Mr A. Rahmans family, they are more comfortable to seek treatment from one of the private GP nearby since the GP himself is her wifes cousin and the treatments fee is cheaper compared to other private GP. Furthermore, the service given is better compared to government health clinic. Since the last visit, Mr A. Rahmans wife and few of his grandchildren were having mild flu. His third son also had been admitted to private hospital fro 2 weeks because of Dengue Fever. FOOD BELIEF Basically, they eat variety kinds of foods. However, since Mr A. Rahman has type 2 diabetes mellitus, hypertension and hypercholesterolemia, he usually eats foods that is suitable with his condition. Every morning, he eats Breakthrough bread with diabetic milk. For lunch, he usually takes healthy, balanced diet which contains vegetables, fruits, chicken, meats and fish. He usually takes smaller amount of meat intake. He also eats brown rice which contains less glucose compared to the usual rice. His wife, also restrict her diet due to her diabetes and hypertension problem. She also belief that there is certain kind of food such as cucumber, tea, pumpkin that are categorized as Angin food. So, she usually tried to avoid this kind of food because she believes that this kind of food can lead to bloating, belching and gastritis. She also avoids drinking coffee because she notices that this kind of drink can precipitate her migraine. Mr A. Rahmans family also avoid eating any left over foods. They claimed that eating this kind of food is not good for their health. Therefore, tey always ensure that they eat food that are still hot and fresh. COMPLEMENTARY MEDICINE Besides seeking treatment from hospital, Mr A. Rahmans family also seek treatment from other alternative healer if the condition cannot be cured after seeking treatment from hospital. They believe, a disease is not only caused by infectious agent, but also can be caused by genie. So, in their opinion, it is not wrong to seek treatment from other source like Bomoh or religious leader as long
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as it is not against their religion which is Islam. His wife also can cure minor illness by reciting Quran. Recently, one of his wife brother has been possessed and after brought him to the hospital, the doctor treated him found there was nothing happened to him. They were told by the doctor to bring him home. His brother condition was not improving and they decided to bring him to Bomoh. The condition improved and they were told that someone who hated him had sent black magic to him. Besides believe in Bomoh and religious healer, they also believe the effect of massage therapy as it can improve their energy level and relieve body ache. For Mr A. Rahman himself, besides seeking treatment from hospital, exercise and has food restriction for his diabetes condition, he also consumes some healthy products for his food supplement. Usually he consumes products that have been proven good for health as well as recommendation from his friends. Currently, he consumes Green N Grains Fiber Powder, Nutri Blend, Mixxie 555, Mona Vie. He claimed that all of these supplements have improved his health as well as his familys health a lot. He does not believe in traditional herbs because he believes some of them are not approved by the government. He also believes most of them are toxic to the liver and kidney. He has a bad experience regarding about this traditional herbs because one of his friends suffers from kidney problem after taking one of the traditional medicine. So, he always bewares in taking any traditional herbs. CHILD BIRTH AND CHILD REARING PRACTICES For the breast feeding practice, Mr A. Rahmans wife breast fed all of her children since they were young. 3 of their children had been breast fed up to 66 months and only the last child has been breast fed up to 2 years. She claimed that her bonding with her last child is stronger compared to the other children and compared to the other children, her last child has less fever. For the history of weaning, she usually starts giving blended rice with vegetables, fish and meat after 6 months old. She claimed that her children were growing well and had no growth problem.
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She also does not believe in few taboos practiced before and after delivery. But most of her food during confinement period was soup and grill fish because it was practiced by her late parents. But for her, the is no suck kind of thing. During pregnancy, she also did not take any complementary medicine except for her third son, where she took homeopathy which was introduced by her friend. She claimed that the progression of her third child is better compared to the other children in term of intelligent. After delivery, she practiced traditional medicine such as wearing bengkung and having tuku in order to maintain her bodys shape. At the same time, she also followed all the follow up that was scheduled for her during pregnancy as well after delivery. All her children completed their vaccination. For their children development, they believe that it depend on the type of foods given to them since young. Parents should not pamper their children by giving unhealthy food to them. They also take fever seriously in their children because they believe that this will affect their brain development. For academic purposes, all of their children were given balance education in terms of academic and non-academic. Besides gaining knowledge from school, all of them were given extra tuition to strengthen their core knowledge in school as well as their religious knowledge.

Theme 3 :
23

EPIDEMIOLOGICAL STUDY OF BIOLOGICAL, PHYSICAL AND SOCIAL ENVIRONMENTS AFFECTING THE ILLNESS
BIOLOGICAL FACTOR Mr Abd Rahman is staying in a semi-detached house with his other family members at Ampangan. The area is a well-managed area. The houses environment as well as the surrounding area is clean. There is no bush of rubbish in the neighbourhood that could harbour snakes, insects or dangerous animal that may pose a danger to residents except for the presence of unwelcomed wild monkeys
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from the forest area near to his house. They like to wander around and mess up with the rubbish in the dustbin in front of his house. And regarding this problem, he already complained to the authority but no action is taken. There is no fly inside and outside his house. Even though his area is one of the black areas for dengue, but recently, there is no dengue outbreak at his area. But he and his family still need to use insect repellents on the night time to prevent mosquito bite. In his area, there is a lot of construction work going on. This contributes to the dusty environment. However, this condition does not precipitate his sinus even though he allergies to dust. He also claimed that there is a lot of rat can be found in his store room as well as on the roof. Since they know that rats can lead to many diseases, he and his family have done a lot of things to reduce to number of them. He puts special glue that is specialized to catch rats that pass by it as well as tries the traditional method such as putting a ping-pong fruits to prevent rats from entering his house. He and his wife also put pandan leaves especially in the cupboard because he claimed that cockroaches do not like the smell of pandan. He also complained about his neighbours pet that likes to pass motion and urine at his compound area. The reason he does not like is because it can dirty his house as well as he allergies to fur. PHYSICAL FACTOR Currently, his sons family stays with him and his wife. There is no overcrowding since his house is very spacious. Water and electricity availabilities are adequate. When there is water or electricity cut, usually the authority will give notice prior to disruption. So, they can store water adequately for their usage. However, he did complain about the quality of the water that is supplied to his house. He claimed that the water is muddy and because of that problem, he has already install water filter at the main water supply and this works very efficiently as the water become no more cloudy. He and his family member do not need to boil water sine they already install a filter that can make the water hot or cold. The furniture in his house is well-arranged and the floor is clean. However, the floor is a bit slippery since it was covered by tiles. So, he has already covered it
25

with carpets to prevent him from falling down due to the slippery. Besides that, his wife also does regular mopping on the floor. Since his grandchildren stay with him, they like to mess the floor with their toys and this put him in a danger from falling down. But currently, this is not a major problem to him anymore because he already has his eye operation recently. He also walks barely in his house, but to be safer, we recommend him to wear slipper to avoid any injury to his foot SOCIAL FACTOR Mr Abd Rahman has a close relationship with all the family members, siblings and his neighbourhood. Eventhough he stays far from his siblings, they always contact each other to keep in touch with their life. Once in a blue moon, his siblings will visit him and his family. There is no financial problem in his family since he and his wife have their own pension and all of his children are working. His relationship with his neighbour is good. He claimed that his neighbours are helpful. Whenever he meets them especially in certain occasion, they will have a small talk about their family and life. But, since he has operated his leg because of diabetic foot ulcer, he claimed that he rarely go to the occasion held by his neighbour. Most of the time, he spends his leisure time with watching television, gardening and playing with his grandchildren. There is no problem of transportation as his wife who is also a pensioner is able to drive him to anywhere he wants especially for follow-up for his diabetic condition at KK Ampangan. His house is in good location where there are a lot of shop houses, clinic and police station nearby. His diet control is good. He has reduced his sugar intake as well as his fat intake since he was diagnosed with diabetes mellitus. Apart from diet control, he already stopped smoking.

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Theme 4 :
27

PREVENTIVE CARE

PRIMARY PREVENTION Primary prevention is defined as the action taken to avert the occurrence of disease. As a result, there is no disease. For Mr Abdul Rahman and his family, they always concern about their lifestyle factors to be associated with disease such as healthy balanced diet, exercise, and smoking cessation. As Mr Abdul Rahman himself who has diabetes since 20 years ago, he always ensures that he eats healthy balanced diet. Usually, he and his wife will take brown rice as their staple food since this kind of rice has low carbohydrate content. He also reduces his fat and sugar intake but at the same time eats a lot of fruits and vegetables. However, his children and grandchildren usually do not have healthy balanced diet. They usually like to eat fast food.
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Besides that, he and his family always do an exercise whenever they have their own leisure time. For Mr Abdul Rahman himself, since he just recovers from diabetic foot ulcer, he can only walk nearby to his house every evening. Same goes to his wife, who likes to walk around the neighbourhood every evening and has small conversation with their neighbour. While his children, they will spend their leisure time by playing any sport such as basketball, futsal. Within Mr Abdul Rahmans family, there is none of them who is smoking except his last son. But he dont worry so much of him since his son is not a heavy smoker. The other primary preventive measures that they concern are immunization against infectious disease. According to Mr Abdul Rahman, all his children complete their immunization that is scheduled for them since they were born. They also concern about all the vector that can bring diseases to he and his family especially rats and cockroaches. Usually he will put mouse trap in the store room to reduce their number as well as putting pandan leaves in the cupboard to chase all the cockroaches away. Besides that, he always disposes the waste properly to prevent from breeding of flies. At the same time, he will ensure that his living area is clean since he realizes that sanitation is one of the important components in primary prevention of the disease. To keep his water supply cleans; he has already fixed a filter at the main water supply since the water supplied to his house is a bit muddy. SECONDARY PREVENTION Secondary prevention is defined as the action taken to stop or delay the progression of the disease. Since Mr Abdul Rahman and his wife have been diagnosed with Type 2 Diabetes Mellitus, they always follow their regular check up at Klinik Kesihatan. They are very compliance to the medication given by their doctor. For Mr Abdul Rahman himself who has cataract before, he always has his regular eye check-up every 3 months. At home, they usually monitor their blood glucose level as well as their blood pressure and document them in the special note book.
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Besides that, Mr Abdul Rahman also takes care of his feet from injury. He does his daily foot inspection especially at night time before sleep. He always ensures that he washes his feet every day and wipes it after washing his feet. He also cut his nails straight cut and wears slippers when outside his house to avoid any injury to his feet. For his children, they usually have their regular check-up once a year as this is requested by their working company each year. TERTIARY PREVENTION Tertiary prevention includes the management of established diseases so as to minimize disability and at the same time restore patient to the best level of adaptation. For Mr Abdul Rahman himself who just recovers from diabetic foot ulcer, he always ensures that he will take good care of his foot. Daily foot inspection is done every day to ensure that there is no injury to his foot without he realizes it. He also wears shoes and slippers whenever he walks outside his house. His wife also makes sure that the floor inside their house is away from any sharp object and is not slippery. However recently, he develops foot swelling but he seem not to bother about it as long as it does not affects his life very much. So, we advised him to consult with his doctor for his next appointment because we think this condition has affected his life badly where he cant walk at longer distance now. Overall. I can conclude that Mr Abdul Rahman and his family are aware of all preventive care.

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Theme 5 :

31

HOSPITALIZATION & ILLNESS EXPERIENCE

HOSPITALIZATION AND ILLNESS EXPERIENCE Mr Abdul Rahman was diagnosed with type 2 Diabetes Mellitus since 1990. Since then, he had a few experiences with government and private hospitals. He roughly could tell the differences between government and private hospitals based on his experiences. Currently for his diabetic problem, he has his regular check up at Klinik Kesihatan Senawang. He always complained about the long waiting queue for him to seek for the treatment. He usually needs to wait for more than 30 minutes to see the doctor and the time taken for the doctors to spend with their patients is less than expected. So, no rapport can be build between the doctor and the patient himself. He also complained about the inefficacy of the services in pharmacy
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counter where he also needs to wait for longer time to get his medication. So, for these reasons, he and his family are more preferred to go to private hospital or clinic. He suggested that government hospital should improved their services in term of waiting time to see the doctor as well as waiting time to get the medication. Maybe they should provided more doctors especially in clinic setting since patients are more increasing in number from year to year. He and his family usually go to private clinic or hospital if they suffer any minor illness. This is because short waiting time to see the doctor and more time for consultation. Some more, most of his children and grandchildren has their own insurance to cover for their treatment at private hospital or clinic. However, for his long term drug supply for his diabetic problem, he preferred to go to Klinik Kesihatan Ampangan because the medications in private clinic and hospital are extremely expensive. His current admission was 3 months ago, where he was warded at Senawang Specialist Hospital for 3 days because of pneumonia. He quit satisfied with their services. His last admission in the government hospital was 2009. He did complain about the food served in the government hospital. It was very horrible and tasteless. He also did mention about the crowded condition in the 2nd and 3rd class ward. So, there is no privacy when he stayed in government hospital Thats why, during that admission, he preferred to stay on the first class ward. Besides that, he also did complain about the unskilful staff in government hospital. For example, in order to set a line, multiple attempt had been made. And this was very painful for him In conclusion, Mr Abdul Rahman and his family are more preferred to seek treatment in private hospital or clinic. This is because their services are better than government hospitals even though they need to spend more money.

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Theme 6 :
34

COMMUNITY RESOURCES

COMMUNITY RESOURCES Mr Abdul Rahman stays in Ampangan which is 30 minutes drive from Hospital Seremban. So, it is important for him to know the local community services, so that he and his family can use them in case of any emergency need. The nearest government health resource is Klinik Kesihatan Senawang which is 10 minutes drive from his house. This is the place where he has his regular follow-up. He had also attended a few talk regarding his diabetic conditionHowever, if he and his family suffer from any minor illness, he preferred to go to any nearby clinic such as Klinik Ibnu Sina which is situated near to his house. This is because he is more satisfied with the services given by them compared to the government clinic in term of waiting time and consultation.

35

He also has nephew who has a private clinic. So, he usually discuss with him anything about his condition. Besides that, a lot of his friends has give him lot of inputs about his condition and how to maintain good health. The nearest private hospital is Senawang Specialist Hospital and Tawakal Hospital. He sometimes went to this hospital for his diabetic foot. His children and his grandchildren also prefer to seek treatment from this hospital because they are covered by insurance.

Section C :
36

MANAGEMENT OF INDEX PATIENT

MANAGEMENT OF IDENTIFIED NEEDS OF THE PATIENT AND HIS FAMILY AND APPROPRIATE HEALTH INTERVENTIONS TO RESOLVE THE NEEDS Type 2 Diabetes Mellitus Identify Problem Needs Analysis The index patient, Mr A. Rahman was diagnosed with Type 2 and Diabetes Mellitus for more than 19 years . His wife also has type 2 diabetes mellitus. Mr A Rahman has a strong family history of diabetes. One of his siblings also has type 2 diabetes mellitus. He was initially treated with a combination of oral hypoglycaemic agents and subsequently had insulin therapy added to his regimen following the his admission on 2009. This indicated progression of relative insulin deficiency in relation to his requirements. In addition, he was also afflicted with several known complications of diabetes namely:
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Microvascular: Nephropathy, retinopathy and peripheral neuropathy Throughout our two-year duration of following-up his condition, his control has improved and he is asymptomatic with all the diabetic symptoms. His dose of metformin as well as subcutaneous actrapid has been maintained at 1g BD and 14 unit QID respectively. However, he will increase 2 unit if the glucose reading is more than 8mmol/L.
o

Formulate Organise

& Our objectives for Mr Balakrishnans diabetes include: Maintain optimum glycaemic control: Fasting blood glucose : 4.4-8.0mmol/L HbA1C: <6.5% Address his problems with compliance to the medical treatment as necessary. Early detection any further complications related to diabetes and associated disorders which may occur in his case. The same plan and principles can also be applied for Madam Shamsiah.

Execute

To address the issues related to Type 2 diabetes mellitus, we carried out a few steps during each home visit; namely:

Routine clinical evaluation of their current condition and throughout the interval between each home visit including:

Symptoms of hyperglycaemia: polyuria, polydipsia, polyphagia, nocturia, poor wound healing, recurrent infections
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 Symptoms of hypoglycaemia: weakness, hunger pangs, fainting episodes, tremors et cetera. Symptoms of micro- and/or macrovascular complications such as diabetic nephropathy, retinopathy, neuropathy, coronary artery disease, stroke Possible side-effects of the medications taken. Last blood investigation results at the Health Clinic and private hospital (from the booklet). Relevant physical examinations such as the skin, eye, feet, cardiopulmonary systems, neurological system and the abdomen. Simple investigations including blood pressure measurement, random capillary glucose monitoring, and urine dipstix. Education & counseling on: Type 2 Diabetes Mellitus: Disease Process & Complications Importance of optimal blood glucose control Diabetic Foot & Stump Care Diet modifications Lifestyle modifications ; exercise Recognition of hypoglycemic attack and hoe to prevent it Annual eye review o Progression of his diabetic retinopathy o Corrective surgery for cataract when deemed necessary Encourage the use of a glucometer at home and adopt selfblood glucose monitoring which will hopefully empower the patient and the caretakers in control of the blood sugar levels. Evaluate Mr A Rahman and Madam Shamsiah have a good understanding of the pathophysiological basis of diabetes initially and we supplemented this by sharing and continuously
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reinforcing the importance of optimal blood control and prevention of complications along with ways to achieve these goals. Throughout the two years, his sugar control was moderately good with few episodes of hypoglycaemic attacks which necessitated increases of doses of the insulin adjusted by him and the medical officers at the health clinic. Even though his blood sugar is well-controlled within these 2 years, the progression of his microvascular complications is still progressing. However, the occurrence of macrovascular complication is not occur yet even though he already has diabetes for more than 19 years. This may be the result of optimal control of his blood sugar. Both of them had not experienced any gross symptoms of either hyper- or hypoglycaemia. They have not had any hospitalisation for any problems related to diabetes for the same duration.

Hypertension, Hypercholesterolaemia & Obesity Identify Problems Mr Rahman was first diagnosed with hypertension following his admission on 2009 due to his diabetic foot. Hypercholesterolaemia was diagnosed in 2001. These two are common co-morbidities related to diabetes mellitus and increase his risk for cardiac disease.

Analysis

He has family history of hypertension. However, there is no family history of cardiovascular disorders or hypercholesterolaemia. Since 2009, his blood pressure was relatively stable with the systolic pressure ranging from 120 130 mm Hg while the diastolic pressure ranged from 70 90 mm Hg. The blood pressure was controlled with a single agent, perindopril.
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 He has not experienced any symptoms suggestive of new end-target organ damage since 2009. No eye examination, ECG trace has been documented in his file in KK Ampangan. Good control of the serum lipids is also essential for the control of his hypertension and diabetes Formulate Organise & Our objectives for Mr A Rahmans hypertension & hypercholesterolaemia include:

Maintain optimum blood pressure control: 125/75 mmHg Maintain optimum serum lipid level: o Triglycerides 1.7 mmol/L o HDL cholesterol 1.1 mmol/L o LDL cholesterol 2.6 mmol/L

Address his problems with compliance to the medical treatment as necessary.

Early detection any further complications related to hypertension and hypercholesterolaemia and related/further end-target organ damage which may occur in his case.

Execute

To address the issues related to hypertension, we carried out a few steps during each home visit; namely:

Routine clinical evaluation of his current condition and throughout the interval between each home visit including: Symptoms of hypertension: headache, dizziness et cetera Symptoms of coronary heart disease: chest pain, palpitations, diaphoresis and shortness of breath. Symptoms of heart failure: oedema, breathlessness,
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paroxysmal nocturnal dyspnea and orthopnoea. Symptoms of dyslipidaemia eg. xanthomata. Symptoms of nephropathy and/or retinopathy. Possible side-effects of the medications taken. Last blood investigation results at the Health Clinic (from the booklet) Relevant physical examinations such as the skin, peripheries, eye, cardiopulmonary systems, neurological system and the abdomen. Simple investigations including blood pressure measurement and urine dipstix.

Education & counseling on: Hypertension & Hypercholesterolaemia: Disease Process & Complications Importance of optimal blood pressure control Diet modifications Lifestyle modifications Annual eye review Encourage the use of a personal sphygomanometer at home to monitor the changes in his blood pressure which will hopefully empower the patient and the caretakers in control of the blood pressure.

Evaluate

The index patient has a good understanding of hypertension and hypercholesterolaemia. As with diabetes, we also continued our efforts in imparting some knowledge and encouraged both MrA Rahman, his wife and his children in helping him to achieve his goals in controlling the progression of the disease.
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Throughout the two years, his blood pressure was stable and control sufficed with the same dose of tablet perindopril at 8mg OD.

Diabetic Foot and Peripheral neuropathy Identify Problem Analysis Mr A Rahman has diabetic foot since 2009.

Since being diagnosed with diabetic foot, he had been experiencing significant limitation of movement and in ambulation. This has led to a sedentary lifestyle with most of his time sitting upright on a couch in the living room and this subsequently result in increase his weight. Another important issue is the appropriate care and hygiene of his diabetic foot as well as to prevent any injury to his leg.

Formulate Organise

& For this problem, our objectives for Mr A Rahman include: Optimal care of his feet Prevention of any injury to his leg Prevention of skin infections, injury or ulcers on his feet since his sensation is already affected. Prevention of joint contractures and pressure sores. Increase in physical activity and mobility

Execution

To address this issue, we carried out the following activities during our home visits:

Regular, routine assessment of feet based on clinical history and physical examination. Health education and reinforcement of the importance of controlling his medical illness ie. Type 2 diabetes mellitus,
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hypertension and hypercholesterolaemia which will prevent complications on the feet. Continuous encouragement and promotion of ongoing practice of the exercise. Promotion of muscle strengthening and stretching exercises to improve muscle bulk. Encouragement on performing simple basic activities of daily living at home, as much as possible. Continuous foot examination before going to bed. Suggestion use of shoes inside the house as well as customized shoes due to swelling of the leg.

Evaluation

Mr A Rahman and his family are very well-informed about the appropriate measures of caring for his diabetic foot. There is only one episode of fungal infection in between the nails. From our assessment, the previous ulcer has been well healed.

LONG TERM MANAGEMENT OF PATIENT : CHEMOTHERAPEUTICS Name of Medication Type 2 Diabetes Mellitus Oral Hypoglycaemic Agent Metformin Insulin S/C Actrapid Hypertension/Stroke Prevention Anti-hypertensive Agent Perindopril
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Dosage

1g BD

14 units QID

8mg OD Antiplatelet Aspirin Hypercholesterolaemia Lipid-lowering Agent Lovastatin 20mg ON 75mg OD

LABORATORY FOLLOW-UP INVESTIGATIONS 1. Fasting blood sugar December 2009 July 2010 August 2010 5.6mmol/L 7.6mmol/L 5.1mmol/L

2. Renal Profile 2009 Na K Cloride Urea Creatinine Uric acid Ca eGFR 2010
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131 5 94 7 110 0.41 2.34 60

Slightly low Normal Slightly low Normal Normal Normal Normal Stage 2 CRF

Na K Cloride Urea Creatinine Uric acid Ca eGFR 3. LIPIDS PROFILE 2009 Total Cholestrol Triglycerides HDL LDL Total Cholesterol/HDL 2010 Total Cholestrol Triglycerides HDL LDL Total Cholesterol/HDL

138 4.9 100 8.5 139 0.44 2.16 45

Normal Normal Normal Normal High Normal Normal Stage 3 CRF

5.3 1.75 1.17 3.33 4.5

High Slightly high Normal High

4.5 1.40 1.29 2.57 3.5

Normal Normal Normal Normal

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PROGRESS REPORT AT EACH VISIT 1.FIRST HOME VISIT We made 2 visits for our first themen. Our first CFCS visit was on 9th of October 2009. Then , the second visit was on 12th of October 2009. We came to know him when he was admitted to Tuanku Jaafar hospital on 3rd of September 2009 because of his diabetic foot. He was so excited when we mentioned our intention to take him as our CFCS patient for the next 2 years. Few days prior to the visit, we gave him a call through the phone number that he gave us. I and Benjamin prepared ourselves on what questions we should ask during our visit to ensure that we covered everything according to our first theme. We went to his house around 4pm. It took about 20 minutes to reach at his house. We did not have any difficulty to reach there since my partner is originally from Seremban. So, we managed to reach his house easily. Upon reaching his house, we were warmly welcomed by him and his wife. He used wheel chair because of his diabetic foot. We were served with drinks and some foods. They are very friendly, so we never felt awkward with them. Before we asked about his health-related condition, we had a light conversation with him about his family. So, that good rapport with him and his wife could be built up. Along our conversation, we got in-depth about his diabetic condition. He has been diagnosed with type 2 diabetes mellitus for the past 19 years and already suffered with several microvascular complications of diabetes mellitus.
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During his last admission, where we first time met him in the hospital, he was started with S/C actrapid 14 unit QID. He was also newly diagnosed with hypertension and was started with tablet perindopril 8mg OD and tablet aspirin 75mg OD. During that visit, we found out that Mr A. Rahman is very knowledgeable. He is very aware about his medical conditions which are type 2 diabetes mellitus, hypertension and hypercholesterolemia. He also knew about the complication of his current problem. He has his own BP machine and glucometer. He jots down the BP and glucose reading in his handphone. He knew roughly how to take care about his foot ulcer. His BP during that time is 124/74mmHg. His RBS is 7.3mmol/L. His waist circumference is 87cm. His current medication is : Diabetes : T.Metformin 500mg BD, S/C Actrapid 14 unit before meal QID Hypertension : T.Perindopril 8mg OD, T.Aspirin 75mg OD

Hypercholestrolemia : Lovastatin 20mg ON

When we went through his medications, we found that he did not take the medication correctly. So, we advised him to take lovastatin at night before going to bed. He also had several cardiac risk factors. However, the medical reports regarding his blood tests, urine tests and fundoscopy were incomplete and mostly missing. We were therefore unable to study his disease progress for the past 19 years. During that visit, we requested him to keep the results of his subsequent follow-up in Klinik Ampangan. During that visit also, his wife told us about her concern about her husband newly diagnosed hypertension was a mistake because at home they found that his

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BP was not high. So, we advised him to seek opinion from their next follow up at Klinik Ampangan. During that visit, we managed to advice him about lifestyle modification. We also gave him pamphlets from ministry of health for him to identify the parameters used in monitoring his disease. We also, advised him to jot down his BP and glucose level in a book. So, everytime we come, we could see how controlled his BP and glucose level. We went home at around 6 pm. We glad that we had built a good rapport with our CFCS patient. 2.SECOND HOME VISIT Second home visit was conducted on 30th of December 2009 at around 4pm. As usual, we were welcomed warmly by him and his wife. He was no longer using wheel chair since the ulcer had already completely healed. Before we started talking deeply into our second theme, we enquired about his general condition. His last follow up was done on 17th of September 2009. However, as we requested his investigations result on the last visit, according to him, he was unable to get it. So, we intended to follow him during her next follow up. He also being scheduled for his right eye cataract operation on 6th of January 2010. Currently, he monitored his blood sugar level as well as his blood pressure twice daily in a book. He also takes his health seriously since his last admission. His BP and blood sugar level that he monitored at home is well controlled. The BP reading was between 120/70 to 130/80 and his blood sugar level was between 7 to 9mmol/L. During this visit, he also complained a few episodes of hypoglycaemic attack. He was being advised by the doctor in Klinik Ampangn to monitor his blood sugar level daily and to adjust the insulin unit according to it. We also advised him on what he should do if he notices that he has gone into hypoglycaemic attack.
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He also complained of swelling on the foot that had ulcer previously especially on the night time. He was currently coping the swelling by elevating the legs when sleeping. We advised him to bandage the foot or use any compression stocking on the night time to prevent the swelling from getting worst. Besides a few episode of hypoglycaemic attack and leg swelling, he also complained to us about occasional bilateral paresthesia up to the level of matacarpophalyngeal joint. It was acute in onset, with no known aggravating or relieving factor. So, we advised him to consult with the doctor that treated him in Klinik Ampangan. Otherwise, there was no other active complaint. During that visit, we also conducted physical examination on him. His BP was 118/78, pulse 92 bpm and his random blood sugar was 5.6mmol/L. His left eye was normal, his right eye can only perceive light. We were unable to do fundoscopy as his eyes were constricted. CVS, respiratory and gastrointestinal examination were unremarkable. There was bilateral leg swelling up to the level of ankles, more on the left side. There was a well healed scar on the plantar aspect of left foot. There was fungal infection in the 4th and 5th interdigital web space, bilaterally. He had bilateral loss sensation for proprioception, touch and pain up to the level of metacarpophalangeal joints. There was no loss of joint vibration. After finished with the physical examination, we went deeply into our second home visit theme. Mr A. Rahman gave us full co-operation during the visit. We are glad that our last visit had given him a big impact about his condition. Now, he is more concern about his diabetic condition by measuring his blood glucose as well as his blood pressure daily. 3.THIRD HOME VISIT We had our third visit on 10th of March 2010 with the presence of CSU Sister Hamidah. We arrived there at around 5pm. During our visit, his wife was not around since she had a vacation in Vietnam. So, on our arrival, we had been welcomed by Mr A Rahman and his daughter-in law.

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During this visit, he complained to us worsening swelling on his left affected foot. We did checked on her left foot. On closer examination, his left ankle joint was not in alignment and is deformed. A well healed scar could be seen on the plantar surface of foot. The left foot was warm. All the pulses on the legs are palpable. There was a bony prominence sized 8 x 8cm over the left medial malleolus. There was bilateral pitting oedema over the left foot up to the level of ankles. So, I and Benjamin were thinking of Charcoat Joint. So, we advised him to consult and discuss this problem with his doctor on the next follow-up because we were thinking of the need of orthopaedics referral. Regarding his right cataract eye operation recently, he now claimed that his right vision became alright. He now could recognise people. However, he still needs glasses to read newspaper. Since we missed his previous appointment in Klinik Ampangan, we again unable to get his previous investigations result. During this visit, we checked on his BP and glucose monitoring from the last visit till now. His BP was within the normal range. However, his random blood glucose readings were between 10-11mmol/L. We told him that the readings are not within the normal range. So, sister Hamidah advised him to add 2 units to his insulin injection. His random blood glucose during that visit was 5.8mmol/L which was within the normal range. Mr A Rahman also had stopped taking the energy drink that composed mainly carbohydrate . He also claimed that there were less frequent episodes of hypoglycaemia. We also discussed with him about his increase weight recently. His BMI currently was 30.1. He claimed that, since the discharge from the hospital, he was not exercising anymore because of his foot problem. We promised to look for him the suitable exercise for him without further injuring his ankle. Since his random blood glucose was not within the normal range, during that visit, we emphasized on him about the need of lifestyle management in term of diet restriction and exercising.
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We also encouraged him to protect his foot when walking inside his house as well as around his compound area because we noticed that he did not protect his foot when walking inside the house. At around 7pm, we thanked him and left his house. 4.FOURTH HOME VISIT We went for our fourth CFCS visit on 15th of June 2010. We reached at our patient house at around 5.30pm. He was slightly limping. However, the previous swelling was still there, but has decreased in size. He already consulted the problem with his doctor in KK Ampangan. They told him that the swelling was a complication from the flap transfter. During this visit, he also complained of a sudden lost of vision in his right eye after waking up from sleep. He already saw the ophthalmologist in one of the private hospital in Seremban and was told to have blood clots in his right eye and underwent a laser treatment. Currently, his right eye was only perceive light and hand movement. His left eye was normal. When we monitored his BP and blood glucose that he recorded, we found out that he had 3 episodes of hypoglycaemic attack especially during the night time. So, we advised him to take a tablespoon of glucose before his insulin jab before bed. His blood pressure monitoring showed normal finding fluctuating in between 120/80-130/90. Since now he was able to move, we encouraged him to use stationary bicycle in his house to counteract his increasing weight since our last visit. Besides that, he also complaint to us about change in bowel habit. He noticed that there was alternation between constipation and diarrhoea in his bowel habit for the past 2 months. His appetite was also decreased. However, there was no blood or mucus in the stool. He also did not have any family history of malignancy. So, counselled him about the need of a people above 60 to go for screening for cancer by colonoscopy. we also advised him to consult it with his doctor during his next follow-up (2nd of July 2010).
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We did physical examination on him during that visit. examination of the lower limbs, shows hair loss at the dorsum of the toes as well as clawing of the toes with pes cavus. There was loss of proprioception at the level of the great toe and patchy sensory loss up to the level of ankles. All the pulses was present. No fungal infection seen in between the nails. We also suggested him to get diabetic shoes. After physical examination, we proceed in discussing our theme for this visit. During this visit, we was worrying about his diabetic condition since his eye condition getting worst even though after had laser treatment. We also worried of his likely to get colorectal cancer due to his complaint of change in bowel habit. We left at around 7pm. 5. FIFTH HOME VISIT On 21st of July 2010, we had our 5th visit to our CFCS patient. We went there at about 4pm. We already planned to visit him early that this date. However, we needed to postpone it since our patient and his wife were at Makkah for about 3 weeks. As usual, when we arrived there, we had been greatly welcomed by Mr Abdul Rahman and his wife. They looked very happy and cheerful after one day coming back from Makkah. However, Mr Abdul Rahman still complaint of minimal cough after having it before going to Makkah. As usual, during this visit, we tried to see any improvement on his condition as well as did some physical examination on him. He did complaint to us about his few times of hypoglycaemic attack especially at early morning time . So, we advised him to adjust the insulin dose at night time as well as discuss this problem with the doctor that treats him. During that time, Mr Abdul Rahman and his wife also shared with us the experience of going to Makkah this time. They did complaint about the dusty condition in Makkah because of lots of renovation have been done. And this had contributed to his prolong cough and the needs to wear mask. In Makkah, he did
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complaint of some numbness and left swollen leg because of the needs to walk at least 5km per day in Makkah. He also did mention to us that his glucose level at some times had reach 12mmol/g because he ate lots of Kurma. During the visits also, we discussed with him about his condition. We also advised him to buy customized shoe for his diabetic foot. We also advised him not to put more weight on the affected foot and the need to use walking stick as well as exercise. We also discussed with him regarding our thematic issues. The discussion went on till 7pm. At around 7pm, we end our visit. Even though, it was a long discussion, at least we had achieved our aim. 6. SIXTH HOME VISIT We had our 6th visit to our CFCS house. During this visit, we still did not had our patients blood investigation from KK Ampangan. Currently, the patient was having his follow up at KK Senawang because his wife was also having follow up there. So, it was easy for them to go there together instead of going to different KK. We already went to KK Ampangan for several times. We found out, that there was no documentation of any blood investigation in our patients file. And the doctor there also refused to do it when we suggested them to do blood investigations on him. Luckily, the patient kept all the blood investigations done when he was admitted in private hospital. So, all the blood investigations result that we collected through out this project was from his admission in private hospital. Since we noticed that his kidney was progressively worsening from the blood investigation result, we advised him to not only to be compliance to his medication, he also needs to exercise as well as restrict his diet. Regarding his change in bowel habit, he refused to consult with the doctor anymore since the problem was not there anymore. During that visit, we found out that Mr A. Rahman was a bit tired with all the complications that he had. Furthermore, he was not told by the doctor in KK
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about his kidney problem. So, for him, as long as all this complication did not affected his life, he was not worrying so much. But for us, his condition getting worst with all the complications that he had. We had tried our best by giving him so many advices and counselling to slow his disease progression. We also screened for depression on him. However, he did not have yet. Currently, he still did not have any macrovascular complication.

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Section D : CRITICAL REVIEW OF INDEX PATIENT

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Critical Review and Comments regarding Diagnosis, Management and Preventive Care of the Index Patient in the context of the Community and Family Environment Success in assisting patient to live a healthy lifestyle Throughout the course of our CFCS project, we managed to form a closeknit relationship with our index patient, Mr A Rahman and his family. From our continuous efforts, we noted that there were significant subjective and objective improvements in his lifestyle modification in controlling his medical illnesses. One of the greatest achievements we have accomplished in this family is on health promotion and awareness particularly regarding metabolic syndrome and its associated complications. From time to time, we reinforced the crucial role of compliance in optimal control of the medical illnesses afflicting Mr A Rahaman andhis wife. We have also periodically assessed Mr A Rahmans progress in between intervals. We would share our opinion and advise him accordingly whenever he or his family members have any acute complaints. Furthermore, we also screened his family members for any medical illnesses. From our perspective, we have gained a lot of insight and communication skills in addition to the medical and clinical knowledge particularly on the holistic management of chronic medical illnesses. We have also learnt the vital role of home visits in the community healthcare setting.

LEARNING ISSUE 1 Mr A Rahman was diagnosed with type 2Diabetes Mellitus for 19 years. He has already developed all the microvascular complications. During our 2 years follow-up of Mr A Rahman, we found out that his blood sugar level was within the normal range. However, the nephropathy still get worsening from stage 2 CKD to stage 3 CKD. What is the appropriate management on diabetic patient who already complicated with diabetic nephropathy?
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Diabetes has become the most common single cause of end-stage renal disease. About 2030% of patients with type 1 or type 2 diabetes develop evidence of nephropathy, but in type 2 diabetes, a considerably smaller fraction of these progress to ESRD. Recent studies have now demonstrated that the onset and course of diabetic nephropathy can be ameliorated to a very significant degree by several interventions, but these interventions have their greatest impact if instituted at a point very early in the course of the development of this complication1. The earliest clinical evidence of nephropathy is the appearance of low but abnormal levels ( 30 mg/day or 20 g/min) of albumin in the urine, referred to as microalbuminuria, and patients with microalbuminuria are referred to as having incipient nephropathy1. A higher proportion of individuals with type 2 diabetes are found to have microalbuminuria and overt nephropathy shortly after the diagnosis of their diabetes, because diabetes is actually present for many years before the diagnosis is made and also because the presence of albuminuria may be less specific for the presence of diabetic nephropathy, as shown by biopsy studies. Without specific interventions, 2040% of type 2 diabetic patients with microalbuminuria progress to overt nephropathy, but by 20 years after onset of overt nephropathy, only 20% will have progressed to ESRD1. Once the GFR begins to fall, the rates of fall in GFR are again highly variable from one individual to another, but overall, they may not be substantially different between patients with type 1 and patients with type 2 diabetes. However, the greater risk of dying from associated coronary artery disease in the older population with type 2 diabetes may prevent many with earlier stages of nephropathy from progressing to ESRD. As therapies and interventions for coronary artery disease continue to improve, however, more patients with type 2 diabetes may be expected to survive long enough to develop renal failure. There is good evidence that early treatment delays or prevents the onset of diabetic nephropathy, or diabetic kidney disease. Slowing the progression of diabetic nephropathy can be achieved by optimizing blood pressure (130/80 mm Hg or less) and glycemic control, and by prescribing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker2.

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Studies have shown that ACE inhibitors and ARBs are beneficial in reducing the progression of microalbuminuria in normotensive patients with type 1 diabetes and in normotensive patients with type 2 diabetes3. References : 1. American Diabetes Association . Nephropathy In Diabetes 2. American Family Physician . Diabetic Nephropathy 3. Molitch ME, DeFronzo RA, Franz MJ, Keane WF, Mogensen CE, Parving HH, et al. Nephropathy in diabetes. Diabetes Care. 2004;27(suppl 1):S7983.

LEARNING ISSUE 2 Mr A Rahmans long-term medication regimen included the antihypertensive agent, perindopril at a dose of 4mg OD. Perindopril is a long-acting angiotensin-converting enzyme inhibitor (ACE-i). What is the role of perindopril in the secondary prevention of cardiovascular complications for a patient with concomitant type 2 diabetes mellitus? Based on the Malaysian Clinical Practice Guidelines on Management of Type 2 Diabetes Mellitus published in 2009, ACE-is are the drugs of choice based on extensive data attesting to their cardiovascular and reno-protective effects in diabetic patients.1 Their benefits include good control of hypertension and microalbuminuria/proteinuria in diabetic patients. In recent years, there was the European trial on Reducation Of cardiac events with Perindopril is stable coronary Artery (EUROPA) disease assessing its benefits. The authors of this trial also examined the role of perindopril 8mg versus a placebo in a doublie-blinded randomised controlled diabetic substudy, PERSUADE. Their results found that perindopril helped to reduce major cardiovascular events (end-points: death, non-fatal myocardial infarction, and resuscitated cardiac arrest) in these patients in addition to other preventive care. This reduction trend was of a similar magnitude to that observed in the general population.2 The PROGRESS trial evaluated the effects of a perindopril-based blood pressure lowering regimen in a prospective cohort involving over 6000 patients
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(diabetics and non-diabetics) with a history of stroke or transient ischaemic attack. They found that diabetes increased the risk of recurrent stroke by 35%. Their analysis found a 28% risk reduction in recurrent stroke in patients with diabetes with the perindopril-based therapy; which was equivalent to one stroke avoided among every 16 patients treated for 5 years duration.3 In conclusion, the use of perindopril as an antihypertensive agent for Mr A Rahman is a wise choice with strong supporting evidence that it will prevent many complications including those involving the cardiovascular and neurologic systems. In addition, ACE-inhibitors are also known for fewer metabolic sideeffects as they do not alter serum levels of cholesterol, triglyceride or plasma glucose levels. However, the patient should be empowered with the knowledge of other non-pharmacological ways of optimising the blood pressure such as therapeutic lifestyle changes. References: 1. Clinical Practice Guideline Task Force, Clinical Practice Guidelines (CPG) on Management of Type 2 Diabetes Mellitus (T2DM), 4th Edition, Malaysian Endocrine & Metabolic Society, Ministry of Health Malaysia 2009. 2. Verma S, Leiter LA, Lonn EM, Strauss MH. Perindopril in diabetes: perspective from the EUROPA substudy, PERSUADE. Eur Heart J. 2005 Jul;26(14):136978. 3. Berthet K, Neal BC, Chalmers JP, MacMahon SW, Bousser MG, Colman SA, Woodward M; Perindopril Protection Against Recurrent Stroke Study Collaborative Group. Reductions in the risks of recurrent stroke in patients with and without diabetes: the PROGRESS Trial. Blood Press. 2004;13(1):7-13.

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Section E : FINAL FOLLOW-UP OF INDEX PATIENT

We made our final home visit to Mr A Rahmans home26th of August 2011. As usual, we were welcomed warmly by Mr A Rahman and his wife into their living room. My partner and I took some time to chitchat with the family. We informed them that we are going for our senior clerkship-shadow housemanship tenure in Hospital Batu Pahat, Johor. We also took the opportunity to enquire about the family particularly Mr A Rahmans condition.
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Since our last vist then, Mr Balakrishnan has been healthy with no active or acute complaints. He was diligently performing the exercises at home daily. His leg has progressively well. The ulcer is completely healed. He allowed us to have a look at his BP and glucose monitoring . Results taken showed very good control of his hypertension and diabetes. His blood pressure and fasting blood sugar was within normal range. We were very happy with this progress and showed a vast improvement in his glycaemic and blood pressure control. His current prescription consists of tablet aspirin 75mg OD, tablet perindopril 4mg OD, tablet metformin 1g BD, subcutaneous actrapid 14 unit QID. We complimented Mr Bala and the family on their efforts of caring for his health. We also reinforced the importance of compliance to the medical treatment as well as adopting therapeutic lifestyle changes. We informed them that this was our last official visit for the CFCS project and thanked them for the opportunity to engage and learn from them. We soon left their home with a heavy heart. Personally, I feel that I have gained a lot from following-up Mr A Rahman and the family for the past 2 years. It offered me a holistic perspective of healthcare from a family and community-based setting. I hope to be able to adopt some of the soft skills and multi-disciplinary approach I have learned from them; in my future clinical practice.

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Section F : GROUP DISCUSSION & GROUPED DATA

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GROUP MEETING REPORT

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Third Group Meeting minute Meeting Date Time Venue Attended by: 1. Hazwani Hassan 2. Abel Boon 3. Nabila Ramlan 4. Benjamin Liong 5. Yip Henry 6. Nurdiyanah Ghafar 7. Ian Tey Zhe Yuan 8. Ang Chui Munn 9. Barbara Kuok 10.Chew Zi-Yen Items Details Action : Third group meeting : March 11, 2010 : 1.00 pm 1.30pm : Seminar room 1

1.0

Opening remarks

Hazwani Hassan welcomed and thanked the members Info for attending the meeting.

2.0

2.1

Matters Arising The discussion began with analyzing the theme of the All third visit, epidemiological study of how these factors have directly or indirectly contributed to the illness and affected the family, as well as the related issues.

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The issues identified were: 1. Biological factors internal biological conditions that might affect the patients medical wellbeing, e.g. family history, genetic predisposition etc. 2. Physical factors External factors that might contribute to/worsen the patients condition e.g. housing environment, climate etc. 3. Social factors lifestyle factors that influences the medical condition e.g. occupation, dietary habits, smoking etc. The third visit must be accompanied by the CSU sisters. Group members were asked to check their availability with the sisters and the respective patients. Group members were reminded to follow up with their patients progression since the second visit. Next Meeting 3.0 The next meeting will be held tentatively in the second week of April. The exact date will be confirmed then. Closing remarks 4.0 Hazwani Hassan thanked all members for attending the meeting and the meeting was adjourned at 1.35 pm. Info

2.2

All

2.3

All

Info

Prepared by: (Name: Ian Tey Zhe Yuan) Leader Date: Fifth Group Meeting Minutes Date:

Checked by: Ms Hazwani Hassan, Group

71

Date Time Venue

: 11th March 2011 (Friday) : 12.45 p.m. - 1.30 p.m. : Seminar Room 1, IMU CS

Attended by: 1. 2. 3. 4. 5. 6. 7. 8. 9. Hazwani binti Hassan Yip Henry Ian Tey Zhe Yuan Ang Chui Munn Abel Boon Nurdiyanah binti Ghafar Chew Zi-Yen Barbara Kuok Li Lian Benjamin Leong

Absent with apologies: 1. Nabila Ramlan Items Details Action

1.0

Opening remarks Ms. Hazwani welcomed and thanked the members for attending the meeting.

Info

2.0

Matters Arising The fifth theme for CFCS was discussed. Issues to cover All
72

2.1

during the visit were brain-stormed and finalized.

2.2

The major headings for theme were discussed.

All

Theme 5: Hospitalization and illness experience. Patient and familys experience with medical services, suggestion for improvement. Patients experience with diagnostic and therapeutic interventions. o Last visit to hospital/clinic, reasons o Compare government and private hospitals/clinic positive and negative remarks, suggestion for improvements 2.3 List of reports to be submitted: 1. Home visit report 2. Thematic report & presentation slides a. Include summary of patients condition and progress. 3. Group meeting minutes Deadline of submission: July 2011 All

3.0

Next Meeting The next meeting is to be confirmed, tentatively in May 2011. Date and venue of the meeting will be announced to the group subsequently.

Info

4.0

Closing remarks Ms. Hazwani thanked all members for attending the meeting

Info
73

and the meeting was adjourned at 1.30 p.m.

Prepared by:

Verified by:

Ian Tey Zhe Yuan Leader

Ms Hazwani Hassan, Group

Date: 11 March 2011

Date: 11 March 2011

Sixth Group Meeting Minutes

Date

: 26th May 2011 (Thursday)

74

Time Venue

: 3.30 p.m. - 4.15 p.m. : Seminar Room 1, IMU CS

Attended by: 10.Hazwani binti Hassan 11.Yip Henry 12.Ian Tey Zhe Yuan 13.Ang Chui Munn 14.Abel Boon 15.Nurdiyanah binti Ghafar 16.Chew Zi-Yen 17.Barbara Kuok Li Lian 18.Benjamin Leong Absent with apologies: 2. Nabila Ramlan Items Details Action

1.0

Opening remarks Ms. Hazwani welcomed and thanked the members for attending the meeting.

Info

2.0

Matters Arising The sixth theme for CFCS was discussed. Issues to cover during the visit were brain-stormed and finalized. All

2.1

2.2

The major headings for the theme were discussed.

All
75

Theme 6: Community resources. Governmental and non-governmental services available to patient and family hospitals, clinics and paramedic services. Patient support group 2.3 List of reports to be submitted: 4. Home visit report 5. Thematic report & presentation slides a. Include summary of patients condition and progress. 6. Group meeting minutes Deadline of submission: July 2011 All

3.0

Next Meeting The next meeting is to be confirmed, tentatively in July 2011. Date and venue of the meeting will be announced to the group subsequently.

Info

4.0

Closing remarks Ms. Hazwani thanked all members for attending the meeting and the meeting was adjourned at 4.15 p.m.

Info

Prepared by:

Verified by:
76

Ian Tey Zhe Yuan Leader

Ms Hazwani Hassan, Group

Date: 26 May 2011

Date: 26 May 2011

77