PROGRAM

KAJIAN KOMUNITI DAN

KES KELUARGA (KKKK)
FASA III
INDIVIDUAL REPORT
NAMA

:KHIRREN RAO A/L APARAVOO

MATRIC NO
YEAR

:114878

..:4

NAMA PENYELIA :Dr Norhafiza

CASE SUMMARY
Patient Details
Name

. .:Kamariah Muhd Noor

R/N

...:A121247

Age

...:66 years old

Race

..:Malay

Religion

....:Islam

Occupation ...:retired nurse

Address ..... :Lot 111.Taman Seri Binjai,
.16150 Kota Bahru.
.Kelantan
Date of
Admission ..:17 October 2015
Date of
Clerking

:18 October 2015

CASE SUMMARY
My patient,Madam Kamariah Muhd Nur,a 66 year old Malay female with a known
history

of

Ischemic

Heart

Disease

,Diabetes

Miletus

type

2,Stoke,Hypertension,high cholesterol and gastritis was apparently well till 1

week prior to admission whereby she developed recurrent episodes of chest pain
which worsened progressively.The last episode was not relieved by Glyceryl
Trinitrate and was associated with shortness of breath,headache and fatigue.The
patient also complained of loss of appetite ,loss of weight,abdominal pain,
constipation,dysuria,vision and hearing loss.However she denied episodes of
fever,cough,palpitations,profuse

sweating,nausea

and

vomiting.The

patient

attributed her disease to poor diet control as she would eat sweet and fried food
despite knowing the effect of such a diet on her condition.The patient also has a
poor knowledge on how much calories she should take daily and how to calculate
the nutritional value of her food intake.The patient does not have a proper system
for medication intake.She puts all her tablet in a basket without proper labeling
which drug is for what.This maybe a factor which may lead to poor compliance
and should be addressed.The patient also failed to monitor her blood pressure
and glucose level regularly.Arrangements should be made so that proper
monitoring is done in the patient so any increase in values can be looked into in a
brisk pace.
Problem List
-recurrent episode of chest pain which worsened progressively
-loss of appetite
-loss of weight
-shortness of breath
-headache
-fatigue
-abdominal pain
-constipation,
-dysuria
-vision
-hearing loss.
-poor diet control
Family history
The patient's mother is a known case of ischemic heart disease.She has 4
siblings and they are all in a good condition.She has no family history of Diabetes
Miletus,Hypertension and other chronic disease.
Drug history
The patient is currently on Fondaparinux ,Flavix,Cardiprin,Isordil,

Atorvastatin,Pantoprazole,Bisoprolol,Gliclazide and Glyceryl Trinitrate.She has

no known drug allergy and is not on any traditional medication.
Social history
The patient stays with her husband in a wooden house in Kampung Binjai,Kota
Bahru.She is taken care by her youngest son whom is a divorcee.She manages
her expenses using her gratitude money from her service to the government.She
however was keen for donation of bp or glucose monitoring set if feasible.

Description of disease/condition related to patient s case study

The patient,Puan Kamariah is a known case of Ischemic Heart Disease ,Diabetes Miletus
type 2,Stoke,Hypertension,Hypercholestrolemia and Gastritis .As for her current
complaint,she was diagnosed to have acute coronsry syndrome.In the following
segment,a brief description will be given regarding the patients condition with emphasis
being placed on diseases such as Diabetes Miletus,Hypertension,Stroke and Ischemic
heart Disease.
DIABETES MELITUS
Diabetes melitus is a chronic disease caused by inherited and/or acquired deficiency
in production of insulin by the pancreas, or by the ineffectiveness of the insulin
produced. Such a deficiency results in increased concentrations of glucose in the
blood, which in turn damage many of the body's systems, in particular the blood
vessels and nerves.
There are two principle forms of diabetes:

Type 1 diabetes (formerly known as insulin-dependent) in which the pancreas fails to

produce the insulin which is essential for survival. This form develops most frequently in
children and adolescents, but is being increasingly noted later in life.

Type 2 diabetes (formerly named non-insulin-dependent) which results from the body's
inability to respond properly to the action of insulin produced by the pancreas. Type 2

diabetes is much more common and accounts for around 90% of all diabetes cases
worldwide. It occurs most frequently in adults, but is being noted increasingly in
adolescents as well.This is the diabetic type that the patient has.

HYPERTENSION
Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a
diastolic blood pressure (DBP) of 90 mm Hg or more.
Based on recommendations of the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the
classification of BP for adults aged 18 years or older is as follow:
1)Normal: Systolic Blood Pressure lower than 120 mm Hg, diastolic lower
than 80
mm Hg
2)Pre hypertension: Systolic Blood Pressure 120-139 mm Hg, diastolic
...80-89 mm Hg
3)Stage 1: Systolic Blood Pressure 140-159 mm Hg, diastolic 90-99 mm Hg
4)Stage 2: Systolic Blood Pressure 160 mm Hg or greater, diastolic 100 mm Hg or greater
Hypertension may be primary, which may develop as a result of environmental or genetic
causes, or secondary, which has multiple etiologies, including renal, vascular, and
endocrine causes. Primary or essential hypertension accounts for 90-95% of adult cases,
and secondary hypertension accounts for 2-10% of cases.

STROKE
Strokes can be classified into two major categories: ischemic
and
hemorrhagic.Ischemic
strokes
are
caused
by
interruption of the blood supply to the brain, while
hemorrhagic strokes result from the rupture of a blood
vessel or an abnormal vascular structure. About 87% of
strokes are ischemic, the rest being hemorrhagic.
In the 1970s the World Health Organization defined stroke as a "neurological deficit of
cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24
hours"The 24-hour limit divides stroke from transient ischemic attack, which is a related
syndrome of stroke symptoms that resolve completely within 24 hour
In an ischemic stroke, blood supply to part of the brain is decreased, leading to
dysfunction of the brain tissue in that area. There are four reasons why this might happen:
1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)
2. Embolism (obstruction due to an embolus from elsewhere in the body

3. Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)

4. cerebral venous sinus thrombosis.
There are various classification systems for acute ischemic stroke. The Oxford
Community Stroke Project classification (OCSP, also known as the Bamford or Oxford
classification) relies primarily on the initial symptoms; based on the extent of the
symptoms, the stroke episode is classified as total anterior circulation
infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI)
or posterior circulation infarct (POCI). These four entities predict the extent of the stroke,
the area of the brain that is affected, the underlying cause, and the prognosis.
The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on
clinical symptoms as well as results of further investigations; on this basis, a stroke is
classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large
artery, (2) an embolism originating in theheart, (3) complete blockage of a small blood
vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause
identified, or incomplete investigation).
An intracranial hemorrhage is the accumulation of blood anywhere within the cranial
vault. The main types of intracranial hemorrhage are epidural hematoma (bleeding
between the dura mater and the skull), subdural hematoma (in the subdural space)
and subarachnoid hemorrhage (between the arachnoid mater and pia mater).
A cerebral hemorrhage is bleeding within the brain tissue. A cerebral hemorrhage can be
due to either intraparenchymal hemorrhage or intraventricular hemorrhage (blood in
the ventricular system). Most of the hemorrhagic stroke syndromes have specific
symptoms particularly headaches, or have evidence of a previous head injury

Ischemic Heart Disease

Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging
from those for

ST-segment elevation myocardial infarction (STEMI) to presentations

found in nonST-segment

elevation myocardial infarction (NSTEMI) or in unstable

angina. It is almost always associated with

rupture of an atherosclerotic plaque and

partial or complete thrombosis of the infarct-related artery.

DESCRIPTION OF EVIDENCES
Learning Objective 1
To understand the essential components of a good diabetic diet and implement them in
patients settings
1.1 In order to achieve this objective ,I first collected relevant information regarding the
suitable diet regime recommended for diabetic patients.My sources included various
books,journals and websites.There were many interesting articles regarding diabetic
diets.I also referred to some online e-books such as the type 2 diabetes diet book by
Calvin Ezrin.Through my reading,i obtained an overall picture of how dietary
modification helps in diabetic control and the methods on how this diets can be
implemented in the patients daily life.
1.2 However,i noticed that most of my reference materials were written by foreign
authors making some of the dietary preparations not suitable in a local setting.In order to
overcome this,i seeked the help of a dietician from HUSM.He organized a comprehensive
crash course on the dos and donts of diabetic diets and the methods of determining the
calorific value of the patients meal.He also taught regarding the proportion of food that
each patient should take.Besides,i was advised by the dietician to always consider the
patient s comorbidities when determining the right dietary serving for the patient.
Learning Objective 2

2.To solve the problem of non compliance to diet regime

2.1 In order to achieve this objective,the patient was provided with a diary to record her
daily intake on a daily basis.After two weeks,the diary was collected and the patients
dietary habits were analysed.Since prior to that,patient was already educated regarding
diabetic diet.The patient s compliance over the period of 2 weeks can be assessed and
improvement is expected
2.2 The family members were also educated about the role of dietary changes in
improving patients disease and their help were obtained in ensuring patients compliance

Objective 3
To educate the patient regarding her disease(Ischemic Heart Disease,Diabetes Miletus,
Hypertension,Hypercholesterolemia,and stroke) and to improve the patients modifiable risk
factors
1.In order to achieve this objective,more information were obtained regarding the
patients disease from journals,book and websites.
2.The modifiable risk factors were assessed in the patient.She was advised to exercise
more and practice a good diet control.The patient was also advised to make lifestyle
changes to reduce risk of recurrent admissions
3.I also obtained pamphlets and brochures from the clinic as learning tool used to educate
patients