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!!!