Baslar, Isa

Belmonte, Celeste

Brillante, Christie

Bulatao, Jose

Cheng, Monina

Family Case Presentation

GENERAL OBJECTIVE

To re-evaluate a patient currently enrolled in the UST-DFM Family Health Care Program for continuance of care

SPECIFIC OBJECTIVES To identify medical, psychological, social and

economic problems of the index patient and her family

To analyze the family dynamics using the family assessment tools

To assess the stage of the family in the Illness trajectory and aid them until they reach the final stage

To formulate a family health care plan To give recommendations as to the continuation of

care under the Family Health Care Program

GENERAL DATA

F. L. 81 years old Female Single

HISTORY OF PRESENT ILLNESS

CONSULT

REVIEW OF SYSTEMS (-) sweats, (-) insomia, (-)anxiety, (-)interpersonal relationship difficulties (-) color changes, (-) rash, (-) photosensitivity, (-) changes in hair/

nails/skin, (-) itchiness (+) blurring of vision, (-)tinnitus, (-)discharge, (-)epistaxis, (-)discharge

, (-)bleeding gums, (-) throat soreness (-) hemoptysis, (-)chest pain, (-)cough (-)nausea, (-)vomiting, (-) hematemesis, (-) melena, (-) hematochezia, (-) dysphagia,(-)epigastric pain,(-)heartburn (-) heat/cold intolerance, (-)polyphagia, (-)polydipsia (-) polyuria (-) muscle pain, (-) joint pain, (-) varicosities, (-)claudication (-) dysuria, (-)flank pain, (-)frequency,(-)hesitancy,(-)urgency (-)headache, (-) seizures (-) easy bruisability

PERSONAL & SOCIAL HISTORYNon-smokerNon-alcoholic beverage drinkerDenies illicit drug use

Diet: Mixed diet (vegetables, fruits, meat)Store owner, retired teacherBS Education graduateDoes household chores, goes to churches

and market

PAST MEDICAL HISTORY

Malaria in 1938 (10 yrs old)-treated by a family physician

(?) Hypertensive since 2005, with BP elevations of SBP 130-140/ DBP 80-90.

No DM, No Asthma, no PTBNo operations(+) allergy to medicolImmunization: Unrecalled

FAMILY HISTORY

(-) asthma(-) allergy(-)PTB(+)Kidney disease – sister(+) HPN – sister(-) DM(-) Cancer

PHYSICAL EXAMINATIONGENERAL SURVEY: conscious, coherent, oriented to 3 spheres, ambulates with assisstance, not in

cardiorespiratory distressBP 130/80 mmHg PR 92/min RR 20/min Temp

36.7CSKIN: warm, moist, no active dermatosesHEENT: pink palpebral conjunctivae, anicteric

sclerae, (+) cataract,OU, no nasoaural discharge, moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged

NECK: no palpable cervical lymph nodes, supple neck, thyroid not enlarged, no other palpable masses

PHYSICAL EXAMINATIONCHEST: symmetrical chest expansion, no

retraction, clear breath soundsHEART: adynamic precordium, regular rhythm,

apex beat at 5th LICS MCL, no mumursABDOMEN: flat, normoactive bowel sounds,

soft, non-tender, no masses palpated(+) gibbus at level of T6-T7, (+) dextroscoliosisEXTREMITIES: no cyanosis, no edema, pulses

full and equalROM: (+) limitation in bilateral hip flexion,

bilateral shoulder abduction and extension

NEUROLOGIC EXAMINATION: Mental Status: Conscious, coherent, oriented to

three spheres Cranial nerves: pupils 2-3 mm ERTL, EOMs full

and equal, V1V2V3 intact, can raise eyebrows, can close eyes against resistance, no facial symmetry, can shrug shoulder against resistance, can swallow, tongue midline on protrusion

Motor: no tremors, no muscle fasciculations, MMT: 5/5 on all extremities

Cerebellar: Can do APST, finger-to-nose test; no gait abnormalities

DTR’s: ++ on all extremities Sensory: No sensory deficit No Babinski reflex No nuchal rigidity, Brudzinski sign, Kernig’s sign

GERIATRIC ASSESSMENT:Mini Mental State Examination: 30

(normal)Katz Activities of Daily Living Scale- With

assistance in bathing, dressing, toileting, & transfer; with occasional incontinence; feeds without assistance

Geriatric Depression Scale: 3 (normal)

ASSESSMENT OF INDEX PATIENT

OsteoporosisFracture, R hipSenile Cataract, OUDextroscoliosis

FAMILY ASSESSMENT

UST

DAPITANP. N

OVAL BARLIN ST

ELOISA ST

ADELIN

A ST

X

STAIRS

PATIENT’S ROOM

CR

PATIENT’S BED

TV

CABINET

CHAIRCHAIR

E.FAN

TABLE

WIN

DO

WS

ENVIRONMENTAL HISTORY Concrete type, 3-storey building Patient rents an 8 bedroom house She occupies one room and sublets the others Fairly clean , well-ventilated and well-lit Electricity provided by Meralco Water source is tap water Drinking water is commercially available purified

water Toilet Type- flush, Drainage is good Regular waste disposal, no segregation but

regularly collected Do not have pets but there are many stray animals

and pests in the neighborhood Area is accessible by- taxi, jeep, tricycle

FAMILY TREE

Lorenza,81

Jose,30

Adelaida, 27

Andrea,22

Jesus,60 Asuncion, 60

Flora, 81

Clarissa Vivian Serrina

Henry Odelon

Carmelita,62 Esteban,65

Anthony Mae MeAnne,33 Ariel,31

Seth, 6 Michael,35 Arlene,32

Vaughn Matthew,2

Rufo , 72 Inocencia,100

Laganzua Family1209 A.J. Barlin St Sampaloc, ManilaDecember 3, 2009

+ = kidney disease* = HPN

+, *

Family StructureType of Family- Unilaterally extendedOrdinal Position: ThirdSocial Class Pattern : Low Income FamilyFamily Set-Up: Democratic

FAMILY PROFILE

AGE/SEX

RELATION TO HEAD

EDUCATIONAL ATTAINMENT

OCCUPATION

CURRENT HEALTH STATUS

Flora 81/F

Aunt B.S. Education graduate

Retired teacher, store owner

OsteoporosisFracture, R hipSenile Cataract, OUDextroscoliosis

Me-Anne

33/F Wife 2nd year- B.S. Computer Science

Housewife Arachnoid cyst(?), s/p spine surgery (June 2009)

Ariel 31/M Head B.S. Nursing Nurse in San Lazaro

Essentially Normal

Seth 6/M Son Prep student Asthma

FAMILY LIFELINE2002- Ariel and MeAnne were married

and rented a room beside Flora’s2003- Seth was born2007- Seth started Nursery school2009-

(Jan) Flora had a fall which caused hip fracture

(June) MeAnne was diagnosed with a spine cyst and was operated

ECONOMIC PROFILEIncome PhP

22,oooExpenses

FOOD 10,000EDUCATION 3,000MEDICATION 1,000 MISCELLANEOUS

(electricity, water, house rent) 4,000__

TOTAL EXPENSES: 18,000Savings: 4,000

HIGHLY FUNCTIONAL

FAMILY APGAR Flora Laganzua

Me-anne Laganzua

1. Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema.

2 2

2. Ako’y nasisiyahan sa paraan ng pakikipag-usap sa akin ang aking pamilya tungkol sa aking problema.

2 1

3. Ako’y nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas para sa aking ikauunlad

2 2

4. Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pagibig.

2 1

5. Ako’y nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.

1 2

TOTAL (Interpretation: 8-10 highly functional, 4-7 moderately dysfunctional, <4 severely dysfunctional) SCALE: 2-Palagi, 1-Paminsan-minsan, 0-Halos hindi

9 8

PARAMETER

STRENGTH WEAKNESS

SOCIAL [ / ] Open intrafamilial lines of communication[ / ] Absence of animosity/rivalry[ / ] Healthy/supportive intrafamilial relationships[ / ] Healthy/supportive extrafamilial relationships

CULTURAL [ / ] Absence of or very few beliefs/practices that are unacceptable to our culture or negatively affect way of living (e.g. institutionalization of elderly, dependency of married children to parents, value for education, does not advocate family closeness, seeking help from traditional healers, etc.)

RELIGIOUS [ / ] Spirituality is positively influencing way of life[ / ] Practicing one’s faith, enduring because of his faith

PARAMETER STRENGTH WEAKNESS

EDUCATIONAL

[ / ] Level of education is not a hindrance to achievement, livelihood, success[ / ] Level of education facilitates comprehension of most challenging circumstances

ECONOMIC [ / ] Ability to allocate funds appropriately[ / ] Ability to make ends meet most of the time

MEDICAL [ / ] Good compliance with medical management[ / ] Aware and practices wellness and environmental sanitation.

[ /] Inappropriate medical consultation

MODIFIED CAREGIVER STRAIN INDEX

Me-anne Laganzua• Madalas- 2• Minsan – 1 • Halos Hindi – 8

FAMILY LIFE CYCLE STAGE

Family with young children- starts with pregnancy for the 1st child to emergence of adolescents.

FIRST ORDER CHANGE1. Supplying adequate space , facilities and

equipment for the expanding family

2. Meeting predictable and unexpected costs of family life with small children

3. Sharing responsibilities within the extended family and between members of the growing family

4. Maintaining mutually satisfactory sexual relationship and planning for the future children

5. Creating and maintaining effective communication system in the family

6. Cultivating the full potentials of relationship with relatives within the extended family

7. Tapping resources, serving needs, and enjoying contracts outside the family

8. Facing dilemmas and reworking philosophies

.

. .

.

.

SECOND ORDER CHANGE

1. Accepting marital system to make space for children

2. Taking on parenting role3. Re-alignment of relationship

with extended family to include parenting and grandparenting roles

.

.

.

FAMILY ASSESSMENT Family with young children – UNILATERALLY EXTENDED

STAGE IN THE ILLNESS TRAJECTORY

STAGE V: Adjustment to the permanency of the outcome.

Adjustment to the permanency of the outcome

the family realizes that they must accept & adjust to a permanent disability

pattern believed to be temporary must be accepted as permanent outcome

Fractures in the Elderly

Osteoporosis Remodeling does not occur in

trabecular bone, therefore metaphysis is prone to fracture

Pathologic Fractures Decreased muscle mass Postural changes Decreased vibration sense

and proprioception Increased reaction time Visuoperceptual decline Impaired mobility

Fractures in the Elderly

History and Physical Examination

FRAX and DEXA Dietary modification and

exercise regimen Review of medications that

may cause dizziness, syncope, etc

Regular eye exams Safer home:

Slip guards and hand rails Removing objects on floor Storing items in easy to reach

cabinets Improve lighting in the home

Goal rapid return to activities for independent living

Diagnosis History and PE X-ray CT scan

Treatment Immobilization Surgical stabilization Joint replacementNational Center for Injury Prevention and Control 

CDC Injury Center

Fractures in the Elderly

Stiffness – daily active or passive ROM exercises of adjacent joints

Contractures – periodic changes in position

Swelling – elevation of limb Pressure sores – daily

inspection and padding of contact points

Functional impairment – gradual re-introduction of ADLs Merck Manual of Geriatrics. Fractures

FRAX: WHO Fracture Assessment Tool

Senile Cataracta vision-impairing

disease characterized by gradual, progressive thickening of the lens

It is one of the leading causes of blindness in the world today

Age is an important risk factor for senile cataract.

History- decrease visual acuity, increase glare, mild to moderate myopia, monocular diplopia

P.E.- slit lamp examination

Laboratory Studies- screening process to detect coexisting diseases (eg, diabetes mellitus, hypertension, cardiac anomalies)

Imaging Studies- ocular imaging studies (eg, ultrasound, CT scan, MRI)

TreatmentThe definitive management for senile

cataract is lens extraction.No drug is available that has been proven

to prevent the progression of senile cataracts. Medical therapy is used preoperatively and postoperatively to ensure a successful operation and subsequent visual rehabilitation.

Dextroscoliosis

Scoliosis is a medical condition in which a person's spine is curved from side to side or front to back, and may also be rotated

Dextroscoliosis is a scoliosis with the convexity on the right side

SymptomsPainUneven musculature on one side of the spine A rib "hump" and/or a prominent shoulder blade,

caused by rotation of the ribcage in thoracic scoliosis

Uneven hip and shoulder levels Asymmetric size or location of breast in females Unequal distance between arms and body Clothes that do not "hang right", i.e. with uneven

hemlines Slow nerve action (in some cases)

InvestigationStandard method for

assessing the curvature quantitatively is measurement of the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved

Management

The conventional options are, in order: 1. Observation 2. Bracing - for example the Milwaukee

brace 3. Surgery

FAMILY HEALTH CARE PLAN: Index Patient

TYPE OF CARE PROBLEM RECOMMENDATIONSWELLNESS {promotive, preventive}

Patient maintains a balance dietLast immunization: unrecalled

For immunization: Tetanus, Pneumococcal, InfluenzaEncourage ROM exercises daily

MEDICAL Osteoporosis with Fracture , R hip Senile Cataract, OUWith episodes of BP elevations

For Rehabilitation therapyFor orthopaedic consultFor Ophthalmologic consultFor Hypertensive work-up

PSYCHOSOCIAL Patient is unable to go out of the house because of her condition. She said that she goes to different churches everyday before the accident. It is also one of the reasons why she could not follow-up at the OPD clinic.

Encourage the other family members to talk to her more often.A wheelchair would be beneficial to be able to go out and meet other people.

FAMILY HEALTH CARE PLAN: Other family members

TYPE OF CARE FAMILY MEMBER

PROBLEM RECOMMENDATIONS

WELLNESS {promotive, preventive}

Me-AnneArielSeth

Maintain balance dietUpdate immunizationDaily exercise

MEDICAL Me-Anne

Seth

s/p spine surgery for arachnoid cyst(?) June 2009Asthma- last attack unrecalled

For ff-up with Neurology

Avoid triggers

PSYCHOSOCIAL Me-Anne

Stopped working after the operation and decided to be a housewife

She could join organization and do activities other than household chores and caring for her aunt.

THANK YOU!!!