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Case Study (DM)
Case Study (DM)
Health history
A. Demographic profile
Name: R.G
Gender: Male
Age: 41 years old
Birth date: September 23, 1967
Birth place: Pasig , Metro Manila
Marital status: Married
Nationality: Filipino
Religion: Born Again- Christian
Address: Brgy. Pantihan 3, Maragondon, Cavite
Educational background: High school graduate
Occupation: Factory worker in Monterey
Usual source of medical care: Doctor/Healthcare Professional
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D. History of present illness
Patient R.G was handled during our duty at Brgy. Pantihan 3, Maragondon,,Cavite
with the chief complaint of insufficient sleep at night, loss of his weight and scaly of
skin. The laboratory test and special treatment for the patient are not applicable
because this case is base on community setting.
• Pediatric/childhood
• Injuries or accidents
-Urinalysis (pyuria)
• Hospitalization
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-December 2003, Rizal Medical Center, Pasig City, Metro Manila
• Operation
-not applicable
• Obstetric History
-not applicable
• Immunizations
• Allergies
• Medication
-Metformin 500mg/tab
-Gliclezide 80mg/tab
1 tab OD a.c.
1 tab OD
-July 2007 (OPD case), Philippine General Hospital, Taft Avenue, Manila
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F. FAMILY HISTORY
(+)
DM
55 y/o 83 y/o
(+) (+)
HPN CVA
39 38
y/o y/o 37
y/o
41
y/o LEGEND:
37y/o
(+) DM
Female
Male
Patient
16 15 9 y/o Deceased
1 1 2
y/o y/o 3 1 y/
y/ y/ o
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G. SOCIO-ECONOMIC STATUS
Mr. R.G. lives in their own house at Pantihan 3, Maragondon, Cavite. His wife is
selling and making barbeque sticks as the source of their income while his 16 years old
son works as a vendor in a wet market at Dasmarinas, Cavite as additional source of
income. They also received financial support from their relatives in Pasig. They can be
measured up as to poor class family. The patient has no history of drinking alcohol and
cigarette smoking.
H. DEVELOPMENTAL HISTORY
A person may experience midlife crisis between the ages of 35-45 years old, the
“deadline decade”. This occurs when the individual recognizes that he has reached the
halfway mark of life and according to Erik Erikson, the developmental task of the
middle-aged adult is Generativity vs. Stagnation.
As to our patient, who belongs to a middle age group and is suffering from a life-
threatening condition, he had experienced this developmental crisis, which led him to be
non-productive.
Being non-productive led him to be stagnant after the occurrence and diagnosis of
his disease which made him to be dependent with his family, he can’t attend, function and
be able to accomplish his responsibilities as a father, a husband and as part of the
community.
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I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION
Subjective Objective
General
Integument
Skin:
“Hindi makati sa binti, pero ang (+)itchiness (upper extremities)
braso, nangangati” as verbalized (+)scaly skin
by the patient. (-)history of skin disease
Hair:
“Dati malago ang buhok ko” as Thinning of hair, evenly distributed
verbalized by the patient. (+)itchy scalp (scratching)
(+)Oily hair
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Nails:
“Ito matigas na ang kuko ko (+)clubbing of nails (long nails)
kumpara dati” as verbalized by (+)Yellowish nail beds
the patient.
Eyes:
“Malabo na ang paningin ko” as (+)blurry vision
verbalized by the patient. (+)PERRLA
(+)Anicteric sclera
(+)Pale conjunctiva
(+)itchiness
(-)discharge
Ears:
“Malinaw pa naman ang Both ears hears well when the examiner
pandinig ko, pero may sumasakit is 3 feet away
minsan” as verbalized by the (-)cerumen
patient. (-)discharge
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“Medyo hirap akong lumunok” (+)difficulty in swallowing
as verbalized by the patient. (+)lesions on tongue
(+)dental carries
(+)hoarseness of voice
Pink tonsils
(-)bleeding gums
(+) gag reflex
Neck:
“Wala naming problema sa leeg (-)stiffness
ko” as verbalized by the patient. (-)pain
(+)palpable bilateral lymphs
Respiratory:
“Medyo nahihirapan akong RR – 28 bpm
huminga” as verbalized by the (+)difficulty of breathing
patient. (+)wheezes on both lungs
(+)barrel chest
Productive cough
(+)green sputum
History of lung disease: pneumonia,
PTB, 2006
Last chest x-ray: 2007
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Cardiovascular
Central:
Peripheral:
(+)coldness(general)
(+)pallor in hands
(+)clubbing of nails
(+)tingling (sole of feet)
(-)numbness
(-)varicose veins
(-)ulcers
0-1 second, capillary refill
Gastrointestinal:
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Urinary:
Genitalia:
Refused
Musculoskeletal:
Neurologic:
Motor function:
(-)tremors
(-)paralysis
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Sensory function:
Oriented to time, person and place
Hematologic:
Endocrine:
J. FUNCTIONAL ASSESSMENT
Mr. R.G. is a 41 yrs old, male and seriously ill person. Once he felt something wrong
about his condition, he seeks for medical advice. Occasionally, he also had colds in the past. Last
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December 2003, after a consultation from a physician and with accompanying lab result of blood
sugar level (2x done, result is increased 300mg/dl) he was diagnosed of DM type 2. The client
believes that he acquired his illness from his grandfather who also had Diabetes Mellitus.
According to Mr. R.G., eating nutritious food, exercise and religiously taking of prescribed
medication or what nurse’s and Doctor’s advise/suggest will keep him healthy. Due to financial
incapacity, this regimen was not taken into consideration.
Before he was diagnosed with DM type 2, Mr. R.G. is a responsible husband and father to
his wife and kids. He was able to provide the needs of his family. The client possessed a jolly and
fun loving type of personality.
Since his illness started, most of the time, he felt self-pity and worthless. He is always
irritable and angry when he thinks that he was ignored. Because of his condition he became more
depress and the only thing that gave him hope and strength is through prayer.
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IV. Sleep/Rest Pattern
The patient had altered sleep pattern. Each day he only had a maximum of 2 hours of
sleep and despite of that he still fells god upon waking up. He said sometimes the pain he felt put
him into sleep.
V. Nutritional/ Elimination
The patient usually takes a glass of milk in his breakfast and he takes heavy meals more
frequently but after eating he usually felt stomach ache. He has supplements of vitamin B-
complex. He typically drinks more than an 8 glasses of water per day. Patient stated that prior to
his illness he weighted 87kgs but at present he weighs 39kgs.
We noticed that the patient skin is scaly all over his body. He also have lesion in his
tongue and positive dental carries.
The patient usually had 3x bowel movement per week with a dark yellowish brown color
stool, with hard formed in consistency. On the other hand he noted that he frequently void with
dark yellow in color urine and felt some discomfort when urinating.
During the day patient is experiencing excessive sweating in his armpit.
Patient can speak and understand English and Tagalog. He can clearly express himself.
He has 6 children and they were close to each other.
Before patient is very active and usually socializes with his neighbors.
Patient R.G’s family was very supportive and understanding, now that he is battling with
his disease.
The patient is dependent due to his illness.
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VIII. Coping and Stress Tolerance
Before when patient R.G is anxious he wants to be alone, when he is stressed, he prefers
to drink liquor and involved himself in gambling.
When he was diagnosed of DM Type 2 there have been many changes occurred that made
difficult for him to adjust. He cannot perform the usual activities that he had before. When
patient R.G is stressed, he prefers to cry until he falls asleep. When it comes to problem, he tried
to calm himself through prayers.
Patient R.G is a Born Again Christian, before according to the client he always hears
mass every Sunday with his family.
Due to his illness he wasn’t able to go to mass. According to the patient there are many
practices affects his illness.
He wasn’t able to follow therapeutic regimen due to financial problem and a strong faith
to God helps him to get through all the suffering he has.
After what happened, patient R.G is still not seeking for medical assistance due to
financial problem. Religious effort is still a part of patient R.G.’s life.
X. Personal Habits
Before, patient R.G. used to maintain a good personal hygiene and had a diet without
restriction. He used to work as a factory worker 6 days per week and was able to help in doing
household chores when he got home. He had a good sleep pattern of almost 8 hours at night.
Every Sunday he goes to mass with his family and occasionally at his free time he drinks and
smoke with his friends.
At present, due to his illness, patient R.G wasn’t able to perform his usual routine. He had
to stopped from working in able to attend his health needs and become dependent to his family.
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1. Imbalanced Nutrition Less than body requirements
4. Activity Intolerance
III.
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3 Risk for Security July 16, 2009
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