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Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina Family Case Presentation.

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Presentation on theme: "Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina Family Case Presentation."— Presentation transcript:

1 Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina Family Case Presentation

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

3 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

4 GENERAL DATA F. L. 81 years old Female Single

5 HISTORY OF PRESENT ILLNESS Jan 19, 2009 Patient was walking outside the UST church when her umbrella (she uses as a cane) slippped and she fell. Patient was able to stand and walk after the incident. Patient claims to have slight pain and LOM, no edema. No consult done, no medications taken Jan 22, 2009 Due to persistence of symptoms, patient called for a hilot. There was increase in the severity of pain after the massage. edema was noted as well. Jan 29, 2009 Patient consulted a physician due to increase in severity of pain. An Xray was done and revealed hip fracture Patient was advised surgery but she refused CONSULT

6 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

7 PERSONAL & SOCIAL HISTORY Non-smoker Non-alcoholic beverage drinker Denies illicit drug use Diet: Mixed diet (vegetables, fruits, meat) Store owner, retired teacher BS Education graduate Does household chores, goes to churches and market

8 PAST MEDICAL HISTORY Malaria in 1938 (10 yrs old)-treated by a family physician (?) Hypertensive since 2005, with BP elevations of SBP / DBP No DM, No Asthma, no PTB No operations (+) allergy to medicol Immunization: Unrecalled

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

10 PHYSICAL EXAMINATION GENERAL SURVEY: conscious, coherent, oriented to 3 spheres, ambulates with assisstance, not in cardiorespiratory distress BP 130/80 mmHg PR 92/min RR 20/min Temp 36.7 C SKIN: warm, moist, no active dermatoses HEENT: 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

11 PHYSICAL EXAMINATION CHEST: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, regular rhythm, apex beat at 5 th LICS MCL, no mumurs ABDOMEN: flat, normoactive bowel sounds, soft, non- tender, no masses palpated (+) gibbus at level of T6-T7, (+) dextroscoliosis EXTREMITIES: no cyanosis, no edema, pulses full and equal ROM: (+) limitation in bilateral hip flexion, bilateral shoulder abduction and extension

12 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 DTRs: ++ on all extremities Sensory: No sensory deficit No Babinski reflex No nuchal rigidity, Brudzinski sign, Kernigs sign

13 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)

14 ASSESSMENT OF INDEX PATIENT Osteoporosis Fracture, R hip Senile Cataract, OU Dextroscoliosis





19 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

20 FAMILY TREE Lorenza,81 Jose,30 Adelaida, 27 Andrea,22Jesus,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, 72Inocencia,100 Laganzua Family 1209 A.J. Barlin St Sampaloc, Manila December 3, = kidney disease * = HPN +, *

21 Family Structure Type of Family- Unilaterally extended Ordinal Position: Third Social Class Pattern : Low Income Family Family Set-Up: Democratic

22 FAMILY PROFILE AGE/ SEX RELATION TO HEAD EDUCATIONAL ATTAINMENT OCCUPATIONCURRENT HEALTH STATUS Flora 81/FAunt B.S. Education graduate Retired teacher, store owner Osteoporosis Fracture, R hip Senile Cataract, OU Dextroscoliosis Me-Anne 33/FWife2 nd year- B.S. Computer Science HousewifeArachnoid cyst(?), s/p spine surgery (June 2009) Ariel 31/MHeadB.S. NursingNurse in San Lazaro Essentially Normal Seth 6/MSonPrepstudentAsthma

23 FAMILY LIFELINE Ariel and MeAnne were married and rented a room beside Floras Seth was born Seth started Nursery school (Jan) Flora had a fall which caused hip fracture (June) MeAnne was diagnosed with a spine cyst and was operated

24 ECONOMIC PROFILE Income PhP 22,ooo Expenses FOOD 10,000 EDUCATION 3,000 MEDICATION 1,000 MISCELLANEOUS (electricity, water, house rent) 4,000__ TOTAL EXPENSES: 18,000 Savings:4,000

25 HIGHLY FUNCTIONAL FAMILY APGAR Flora LaganzuaMe-anne Laganzua 1. Akoy nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema Akoy nasisiyahan sa paraan ng pakikipag-usap sa akin ang aking pamilya tungkol sa aking problema Akoy nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas para sa aking ikauunlad Akoy nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pagibig Akoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isat-isa. 12 TOTAL (Interpretation: 8-10 highly functional, 4-7 moderately dysfunctional, <4 severely dysfunctional) SCALE: 2-Palagi, 1-Paminsan-minsan, 0-Halos hindi 98

26 PARAMETERSTRENGTHWEAKNESS 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 ones faith, enduring because of his faith

27 PARAMETERSTRENGTHWEAKNESS 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

28 MODIFIED CAREGIVER STRAIN INDEX Me-anne Laganzua Madalas- 2 Minsan – 1 Halos Hindi – 8

29 FAMILY LIFE CYCLE STAGE Family with young children- starts with pregnancy for the 1 st child to emergence of adolescents.

30 FIRST ORDER CHANGE 1. 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.

31 SECOND ORDER CHANGE 1. Accepting marital system to make space for children 2. Taking on parenting role 3. Re-alignment of relationship with extended family to include parenting and grandparenting roles.


33 STAGE IN THE ILLNESS TRAJECTORY STAGE V: Adjustment to the permanency of the outcome.

34 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

35 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 PATHOPHYSIOLOGY

36 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 replacement PRIMARY PREVENTION SECONDARY PREVENTION National Center for Injury Prevention and Control CDC Injury Center

37 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

38 FRAX: WHO Fracture Assessment Tool

39 Senile Cataract a 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.

40 Clinicals History- decrease visual acuity, increase glare, mild to moderate myopia, monocular diplopia P.E.- slit lamp examination Work-up Laboratory Studies- screening process to detect coexisting diseases (eg, diabetes mellitus, hypertension, cardiac anomalies) Imaging Studies- ocular imaging studies (eg, ultrasound, CT scan, MRI)

41 Treatment The 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.

42 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

43 Symptoms Pain Uneven 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)

44 Investigation Standard 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

45 Management The conventional options are, in order: 1. Observation 2. Bracing - for example the Milwaukee brace 3. Surgery

46 FAMILY HEALTH CARE PLAN: Index Patient TYPE OF CAREPROBLEMRECOMMENDATIONS WELLNESS {promotive, preventive} Patient maintains a balance diet Last immunization: unrecalled For immunization: Tetanus, Pneumococcal, Influenza Encourage ROM exercises daily MEDICALOsteoporosis with Fracture, R hip Senile Cataract, OU With episodes of BP elevations For Rehabilitation therapy For orthopaedic consult For Ophthalmologic consult For Hypertensive work-up PSYCHOSOCIALPatient 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.

47 FAMILY HEALTH CARE PLAN: Other family members TYPE OF CAREFAMILY MEMBER PROBLEMRECOMMENDATIONS WELLNESS {promotive, preventive} Me-Anne Ariel Seth Maintain balance diet Update immunization Daily exercise MEDICALMe-Anne Seth s/p spine surgery for arachnoid cyst(?) June 2009 Asthma- last attack unrecalled For ff-up with Neurology Avoid triggers PSYCHOSOCIALMe-AnneStopped 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.


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