Case Scenario: DIABETES

Physician’s Guide

 Mrs Anna Leynes, 50y.o. female, office secretary consulted because of a nonhealing
wound on the right big toe for 4 weeks.

 The patient complains of minimal pain and redness on her right big toe. She has taken
Amoxicillin 500mg/cap 3x a day for 1 week and no resolution was noted. She does not
have fever and she has no known history of trauma. She occasionally wakes up at night
to urinate but she has no symptoms of weight loss, polyphagia or polydipsia. She has
tingling sensations on her feet but it would spontaneously go away.

 Two months ago, she had her annual physical examination in the company where she
works. She was given a referral from their company nurse for “further evaluation of
elevated blood sugar”. Her laboratory tests include FBS, lipid profile and 12 LECG. FBS
was 8.5 mmol/L but all other tests results are within normal limits. She has history of pre-
eclampsia during her last pregnancy in 2005. She has strong family history of diabetes
and her father died of kidney disease.

 Vital signs taken on consult was 110/70 HR 92/min RR 18/min BMI 30kg/m2. The rest
of the physical exam was unremarkable except for wound associated with swelling and
reddish to violaceous discoloration of the right big toe.

TASKS:
1. Review the family genogram provided.
2. Identify the family member/s that needs to be invited in the Family Meeting
3. Demonstrate how to do Family CEA in this family.
 Case Scenario: DIABETES
Patient’s Guide

 You are Mrs Anna Leynes, 50y.o. female, office secretary consulted because of a
nonhealing wound on the right big toe for 4 weeks. You complain of minimal pain and
redness on your right big toe. You have taken Amoxicillin 500mg/cap 3x a day for 1 week
and no resolution was noted. You do not have fever and you do not recall any trauma to
the affected foot. You occasionally wake up at night to urinate but you have no symptoms
of weight loss, polyphagia or polydipsia. You have tingling sensations on your feet but it
would spontaneously go away.

 Two months ago, you had your annual physical examination in the company where you
work. You were given a referral by the company nurse for “further evaluation of elevated
blood sugar”. Your laboratory tests include FBS, lipid profile and 12 LECG. FBS was 8.5
mmol/L but all other tests results are within normal limits. You have history of pre-
eclampsia during your last pregnancy in 2006. You have a strong family history of
diabetes and your father died of kidney disease.

 Vital signs taken on consult was 110/70 HR 92/min RR 18/min BMI 30kg/m2. The rest
of the physical exam was unremarkable except for wound associated with swelling and
reddish discoloration of the right big toe.

 You are married to Roberto 55 years old, have 3 children (Samantha 18, Elise 14 and
Piolo 10)

 You are not convinced that you have diabetes since you feel well and this was the first
time in 10 years in the company that you were referred for evaluation after the annual
physical exam. You eat healthy foods – vegetables, fish and less carbohydrate.

 ACT out the script described below.

o BELIEF: Your blood sugar is normal since you feel well. You just need an appropriate
antibiotic to heal the wound on your foot.

o FEELING: You are mildly concerned and just curious

o CONTEXT: You eat vegetables and less carbohydrate since you want to be healthy in
order to keep your job. Life is not hard for your family but you need to work to finance the
education of your children.

o CONSEQUENCES: You are not bothered nor you fear of any consequences of the
condition because you don’t believe you have diabetes.

 Answer questions posed by the physician based on this summary. Do not

volunteer any information. You may ask the physician for clarification.

 If the physician asks questions that are not covered by this summary, make sure
that your responses do not contradict the information provided in the summary.

 Do not state your feelings unless the physician specifically asks for it or reflects it
back to you. If he does, then immediately state your feelings.

 Until the physician asks you to explain your feelings, do not do so. If he does, then
explain the context of your feelings.
 Case Scenario: DIABETES
Family Member’s Guide

 Mrs Anna Leynes, 50y.o. female, office secretary consulted because of a

nonhealing wound on the right big toe for 4 weeks.

 The patient complains of minimal pain and redness on her right big toe. She has
taken Amoxicillin 500mg/cap 3x a day for 1 week and no resolution was noted.
She does not have fever and she has no known history of trauma. She
occasionally wakes up at night to urinate but she has no symptoms of weight loss,
polyphagia or polydipsia. She has tingling sensations on her feet but it would
spontaneously go away.

 Two months ago, she had her annual physical examination in the company where
she works. She was given a referral from their company nurse for “further
evaluation of elevated blood sugar”. Her laboratory tests include FBS, lipid profile
and 12 LECG. FBS was 8.5 mmol/L but all other tests results are within normal
limits. She has history of pre-eclampsia during her last pregnancy in 2005. She
has strong family history of diabetes and her father died of kidney disease.

 Vital signs taken on consult was 110/70 HR 92/min RR 18/min BMI 30kg/m2.
The rest of the physical exam was unremarkable except for wound associated
with swelling and reddish to violaceous discoloration of the right big toe.

 She is married to Roberto 55 years old, have 3 children (Samantha 18, Elise 14 and
Piolo 10).

 She is not convinced that she has diabetes since does not feel any symptoms and this
was the first time in 10 years in the company that she was referred for evaluation after
the annual physical exam. She eats healthy foods – vegetables, fish and less
carbohydrate.

 ACT out the script described below.

HUSBAND
o BELIEF: Her blood sugar is high and the wound on her foot can lead to loss of her leg.
o FEELING: You are very anxious about your wife’s condition
o CONTEXT: One of your neighbors was amputated 2 months ago. He just had a blister on
his foot and two months later his leg was amputated
o CONSEQUENCES: You fear the complications that the diabetes will bring to the patient.

MOTHER
o BELIEF: Your daughter’s blood sugar is high and the wound on her foot means it needs
to be controlled.
o FEELING: You are mildly anxious about your daughter’s condition
o CONTEXT: Many members of your husband’s family have diabetes. Some get well and
some are not lucky just like the patient’s father.
o CONSEQUENCES: You fear the complications that the diabetes will bring to the patient.
 DAUGHTER
o BELIEF: Your mother’s wound is related to her blood sugar.
o FEELING: You are mildly anxious and curious about your mother’s condition
o CONTEXT: You are not so familiar with diabetes but you have searched the internet and
you know how important her diet is in controlling her sugar and improving her wound. You
have also searched some complications but how it happens is not really clear to you.
o CONSEQUENCES: You fear the complications that the diabetes will bring to the patient.

 Answer questions posed by the physician based on this summary. Do not

volunteer any information. You may ask the physician for clarification.

 If the physician asks questions that are not covered by this summary, make sure
that your responses do not contradict the information provided in the summary.

 Do not state your feelings unless the physician specifically asks for it or reflects it
back to you. If he does, then immediately state your feelings.

 Until the physician asks you to explain your feelings, do not do so. If he does, then
explain the context of your feelings.
 Case Scenario: Diabetes
General Guide

Time allotment:
O 30 minutes for the orientation (point person and group members)
O 30 minutes for the workshop proper
O 20 minutes for the plenary

1. Ask the physicians and the observers to review the genogram and determine
who should be invited to join in the family meeting.

2. Ask the physicians to read the scenario carefully. Remind them that they need to
demonstrate the steps of CEA on the simulated family. Let them assume that
they already know the members of the family and the clinical scenario prior to
the scheduled meeting. Give copies of the Family CEA checklist

3. Ask the observers to closely observe a particular actor and how the people in
the meeting responds to their assigned actor.

4. At the end of the interview, ask feedback from the observers, the patient, the
family members and the physician counselor regarding their experience in
handling the case scenario. Please make a FEEDBACK on how CEA was
conducted appropriately / inappropriately.

The following are the steps for CEA.

1. Catharsis done on every member present

What did you think?
What did you feel?
What do you fear the most?
Summarize feeling and perception. What was/were the misperception/s?
Prioritize based on your list

2. Educate by correcting the misperception.

3. Propose an action to be taken

 Gave specific action (treatment, prevention and follow-up)
 Probed for capacity of the patient to comply
 Provided safety net - to prevent mistakes/error
o Do you have questions?
o Is there anything else you want to clarify?
CHECKLIST of activities for Counselors Done Not done REMARKS
conducting a Family CEA
Introduced self to patient
Positioned the family members in a manner that is
conducive in providing balanced attention and
equal opportunities to speak and be heard
Asked what the patient and each member knows
about the disease
Asked what the patient and each member felt
about the condition OR reflected back the feelings
of the patient and family member
Probed for the context of the feelings of every
person in the meeting
Summarized the perception of the patient and
each member (Identified “ECM/s”)
Prioritized the list of ECM/s identified
Focused educating the family on the priority
perception/ ECM identified
Proposed a plan of action WITH the family
Checked for family’s capacity to comply with the
management
Provided safety net to ensure patient safety (or
prevention of mistakes)
Non-verbal and paralinguistics expressed
empathy and unconditional positive regard for the
patient and the family
Additional notes from the observers: