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Mid-Course Report December 2009. Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest.

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Presentation on theme: "Mid-Course Report December 2009. Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest."— Presentation transcript:

1 Mid-Course Report December 2009

2 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans CUDAL Address: 1016 Eloisa St. Sampaloc Manila Contact No Mini-Nutritional Assessment Score At risk of malnutrition Mini Mental State Exam Can not be assessed Geriatric Depression Scale Can not be assessed Communal Family in Later life Breadwinner Dra. Efegenia Soliven (daughter living abroad) Decision-maker Dra. Efegenia Soliven (daughter living abroad) 1˚ Caregiver Cecilia Cabais (informal caregiver) MCSI Madalas-2 Minsan-5 Halos hindi-4 Dorothea Cudal Female 97 y/o Dementia Hearing Loss, AU s/p hip replacement (2004) Multivitamins, 1 tab OD Calcium Carbonate, 1 tab BID Medical 1. Continue Multivitamins and Calcium Wellness 1. Dietary advise- eat more vegatebles, fruits, eggs, drink milk and other fruit drinks. 2. Osteoporosis screening 3. Maintain low salt and low fat diet 4. Encourage passive ROM exercises Psychosocial 1. Patient has good personal relationship with caregivers. 2. She is able to talk to her daughter who lives in USA by telephone. She sees her daughter and family once a year. 3. We can encourage the family to make their visit more often and call her more often.

3 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans MIGUEL Address: 1016 Eloisa St.Sampaloc Manila Contact No Mini-Nutritional Assessment Score Not at risk Geriatric Depression Scale Not assessed- patient was in Ilocos Communal Family in Later years Breadwinner Lydia Miguel Decision maker Lydia Miguel *Patient owns the house and rents it to boarders. It is her source of income. Lydia Miguel Female 60 y/o SAH Stage II, poorly controlled Atenolol (Therabloc) 50mg, 1 tab OD Multivitamins, 1 tab OD Folic Acid, 1 tab OD Medical 1. Continue current medications. *Patient is currently in Ilocos for renovation of their house. Caregiver said that they talk to her often on the phone and claims that she has good BP control. Psychosocial 1. Maintain good relationship with caregiver. 2. Encourage her to vent feelings regarding the unexpected financial burden of rebuilding her house which was destructed because of the typhoon Pepeng.

4 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans LANOT Address 1134 Prudencio St. Sampaloc Manila Contact No Mini-Nutritional Assessment Score Not at risk Mini Mental State Exam Normal Geriatric Depression Scale Normal Unilaterally extended Family in Later years Breadwinner Susan Lanot (daughter) Decision maker Susan Lanot (daughter) 1˚ Caregiver Florabel Teodoro (neice) MCSI Madalas-1 Minsan-1 Halos hindi-9 Anicia Lanot Female 76 y/o DM type 2, uncontrolled SAH stage II, controlled ASHD, CAD, LVH, NIF, Class IIB s/p CVA (2003) s/p UGI endoscopy 11/3/08 s/p AKI secondary to Acute Blood loss secondary to gastric ulcer, resolved (2008) Metoprolol 50mg/tab, 1 tab BID Amlodipine 5mg/tab, 1 tab OD Insulin 26 U am and 14 U pm Medical 1. Continue current medications 2. Daily BP monitoring 3. Glucose monitoring TID 4. Follow-up referral to ENT (hearing loss) and Ophthalmology (blurring of vision) 5. Screening for gastritis with every family visit 6. Encourage passive ROM exercises by caregiver *She is being seen by Endo-Med as well, for her DM. Her caregiver already consulted the dietary for nutrition counseling is following their advice. *Patient had episodes of epigastric pain and was given Domperidone which gave relief. Psychosocial 1. Maintain good interpersonal relationship with caregivers and relatives in the household

5 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans LABRADOR Address 930 Quezon Blvd St. Sampaloc Manila Contact No Mini Nutritional Assessment At risk for malnutrtion Geriatric Depression Scale cannot be fully assessed Mini Mental State Exam cannot be fully assessed Unilaterally extended Family in Later life Breadwinner Virgilio Jacob (son-in-law) Decision maker Angelita Jacob (daughter) 1 Caregiver Angelita Jacob (daughter) MCSI Madalas-1 Minsan-4 Halos hindi-6 Luciana Labrador, Female 76 y/o Alzheimer's disease Xerosis Multivitamins, 1 tab OD Medical 1.Continue MVP Wellness 1. Maintain a balance diet 2. Update immunizations: (Pneumococcal, Influenza, Tetanus) 3. Fall precaution 4. For Osteoporosis screening Psychosocial 1. Maintain good interpersonal relationship with her daughter and her family.

6 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans VICTORIA Address 948 Adelina St. Sampaloc, Manila Contact No Mini Nutritional Assessment At risk for malnutrition Mini Mental State Exam Normal Geriatric Depression Scale Normal Nuclear Family in Later life Breadwinner Supina Victoria (daughter in law) Decision Maker Supina Victoria (daughter in law) Beatriz Victoria Female 85 y/o SAH stage II, poorly controlled Gouty Arthritis Amlodipine 5mg/tab, 1 tab OD Metoprolol 50mg/tab, 1 tab OD Petroleum Jelly, apply TID on affected areas *Patient’s medications are not being taken regularly because of financial constraints. Medical 1.Continue current medications 2.MVP, 1 tab OD 3.For Ophthalmology referral (blurring of vision not fully corrected by glasses) Wellness 1. Maintain balance diet 2. Update immunization (Pneumococcal, tetanus, Influenza) Psychosocial 1.Smoking cessation 2.Improve relationship with her daughter –in-law and her siblings. 3.Proper budgeting

7 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans RALLOS Address 940 Quezon Blvd. Sampaloc Manila Contact No Mini Nutritional Assessment Not at risk Mini Mental State Exam Normal Geriatric Depression Scale Suggests depression Nuclear Family with adolescents Breadwinner Romeo Rallos Decision maker Romeo Rallos 1 Caregiver Madeline Rallos (wife) MCSI Madalas-1 Minsan-1 Halos Hindi-9 *Family gets monthly disability pension. Romeo Rallos Male 51 y/o DM type 2, poorly controlled Diabetic foot, left; s/p AKA May 2008 in PGH Metformin 500mg/tab, 1 tab TID *Patient’s medications are being taken only BID because of financial constraints. There is no regular CBG monitoring. Medical 1.Continue current medications 2.MVP, 1 tab OD 3.For Ophthalmology referral – baseline evaluation of Dm complications 4.For BUN, serum creatinine, HBA1C Wellness 1.Update immunization (Pneumococcal, tetanus, Influenza) Psychosocial 1.Patient is currently in constant communication with their parish priest. 2.Maintain good interpersonal relationship with his wife and children. 3.Further exploration of possible depression

8 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans RAGAZA Address: 932 R. Papa St. Manila Contact No: Mini Nutritional Assessment Malnourished Bilaterally Extended Family in later life Breadwinner Marilou Ragaza (daughter) Decisionmakers Marilou Ragaza (daughter) Caregiver Marilou Ragaza (daughter) MCSI Madalas:4 Minsan: 4 Halos hindi: 3 Flaviana Ragaza Female 81 y/o Alzheimer’s disease Senile cataract, OD Malnourished MVP 1 tab OD Medical 1. Referral to Neurology 2. Referral to Ophthalmology 3. Referral to dietary for counseling Wellness 1. Ensure 2 glasses/day 2. Update immunizations (tetanus, influenza and pneumococcal) 3. Encourage proper hygiene Psychosocial 1. Encourage family support for cataract surgery

9 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans RAGAZA Address: 932 R. Papa St. Manila Contact No Mini Nutritional Assessment Malnourished Geriatric Depression Scale Normal Bilaterally Extended Family in later life Breadwinner Marilou Ragaza (daughter) Decisionmakers Marilou Ragaza (daughter) Crispin Ragaza Male 80 y/o SAH stage 1, controlled Malnourished Amlodipine 10mgtab OD MVP 1 tab OD Medical 1. Daily BP monitoring at health center 2. Continue current medications 3. Referral to dietary for counseling Wellness 1. Ensure 2 glasses/day and low salt and low fat diet 2. Update Immunizations (tetanus, influenza and pneumococcal) Psychosocial 1. Encourage family support and daily hygiene

10 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans LAGANZUA Address 1209 A.J. Barlin St Sampaloc, Manila Mini Nutritional Assessment At risk for malnutrition Geriatric Depression Scale Normal Unilaterally extended Life Cycle Stage Family in later years Breadwinner Flora Laganzua Decision maker Flora Laganzua 1 Caregiver None Flora Laganzua Female 81 y/o Osteoporosis Fracture R hip Senile Cataract OU Dextroscoliosis Underweight Psychosocial problems *Patient currently has no caregiver Multivitamins 1 tab OD Mefenamic Acid 500 mg/tab Calcium gluconate 1 tab OD Medical 1. For hypertensive work-up 2. Refer to Orthopedics 3. Refer to Rehab 4. Refer to Ophthalmology 5. Update vaccination (Tetanus, Pneumococcal, Influenza) Wellness 1. Advise balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily 3. Encourage to ambulate with assistance 4. Educate patientson benefit of healthy living and seeking to improve one’s health Psychosocial 1. Encourage good and healthy relationship with borders 2. Encourage borders to spend quality time with the patient

11 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans GRAVANSOS Address: 1041 Adelina St. Sampaloc Manila Mini Mental State Exam Can not be assessed Geriatric Depression Scale Normal Extended Launching Family Breadwinner Zaldy, Polly, Myrna Decision maker Zaldy Caregiver Employed by patients daughter Myrna MCSI Madalas :0 Minsan: 9 Halos hindi 1 Soledad Gravansos Female 79 y/o Parkinson’s disease Psychosocial problems Biperidine (Akineton) 2mg/tab BID Medical 1. Continue present medications 2. Update vaccination (Influenza, Tetanus, Pneumococcal) 3. Refer to neurology 4. Suggest Multivitamins 1 tab OD Wellness 1. Advice balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily Increase oral fluid intake 3. Encourage to ambulate (w/assistance) 4. Educate patient on benefit of healthy living and seeking to improve one’s health Psychosocial 1. Caregiver-focused social support 2. Encourage good and healthy relationship with family members and peers 3. Encourage each family member to spend quality time with the patient

12 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans CAABAY Address 1029 Adelina St. Sampaloc Manila Contact No Geriatric Depression Scale Normal Extended Launching Family Breadwinner Marlon Dela Cruz Decision maker Marlon Dela Cruz Cristy Caabay Female 66 y/o SAH St. 2, uncontrolled t/c Senile Cataract Psychosocial problems Losartan 100mg/tab OD Amlodipine 5mg/tab OD Medical 1. Continue with present medications 2. Daily BP monitoring and recording 3. For: CBC with platelet, Urinalysis, Lipid Profile, 12L- ECG, Chest X-ray, FBS 4. Update vaccination (Pneumococcal, Influenza, Tetanus) 5. For referral to Ophthalmology Wellness 1. Advice balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily 3. Encourage to ambulate w tih assistance 4. Continue vitamins supplementation 5. Educate patients on benefit of healthy living and seeking to improve one’s health Psychosocial 1. Encourage good and healthy relationship with family members and peers 2. Encourage each family member to spend quality time with the patient

13 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans RICARDO Address: 1829B Sisa St, Sampaloc, Manila Contact No Mini Nutritional Assessment Not at risk for malnutrtion (previous diagnosis) Mini Mental State Exam Can not be assessed Geriatric Depression Scale Can not be assessed Unilaterally extended Launching Family Breadwinner Vivian (patient) Decision maker Vivian (patient) Vivian Ricardo Female 55 y/o SAH St 2, uncontrolled ASHD, CAD, LVH t/c Musculoskeletal strain t/c Gastritis 2 to chronic ASA use Metoprolol 50mg BID ISMN 30mg OD ASA 80mg OD Simvastatin 20mg ODHS Losartan 50mg + Hydrochlorothiazid e 12.5mg OD Omeprazole 20mg OD Medical: 1.Daily BP monitoring 2.For 12L ECG, lipid profile, FBS 3.For ophthalmologic examination Wellness: 1.Recommend light snacks every 2 hours for waking hours 2. Recommend DASH diet 3.Strict compliance with medications 3. Reading daily * Patient’s relatives have been refusing visits due to scheduling conflicts. The patient is only available at 4am and 10pm due to her work. Suggest discharge

14 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans RICARDO Address 1722 Ibarra St, Sampaloc, Manila Contact No Mini Nutritional Assessment Not at risk (score 12) Mini Mental State Exam Mild Impairment (score 23) Geriatric Depression Scale Normal (score 5) Bilaterally extended Family in later years Breadwinner Rosario Castillo (Daughter) Decision maker Rosario Castillo (Daughter) Concepcion Ricardo Female 81 y/o SAH St 2, controlled t/c Senile cataract OD s/p cataract surgery OS Allergic Contact Dermatitis 2 to Rubber Sandals, both feet Amlodipine10mg + Valsartan 160mg OD ASA 80mg OD Petroleum jelly OD and prn Medical: 1.Daily BP monitoring and recording 2.For ophthalmologic examination (offered and refused) 3. Screening for gastritis symptoms with every family visit Wellness: 1.Recommend light snacks every 2 hours for waking hours 2. Recommend DASH diet 3.Strict compliance with medications 4. Increase ADL 5. Encourage daily reading of newspapers Psychosocial: 1.Encourage more ocial involvement with neighbors

15 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans ROFO Address: 1726B Ibarra St, Sampaloc, Manila Contact No Mini Nutritional Assessment Not at risk (score 14) Mini Mental State Exam Mild impairment (score 27) Geriatric Depression Scale Normal (score 3) Bilaterally Extended Family in Later Life Breadwinner Edna Garcia (daughter) Decision maker Edna Garcia (daughter) Lydia Rofo Female 79 y/o SAH St 1, controlled Gouty arthritis ASIS fracture, left, s/p skeletal traction Amlodipine 5mg BID Verapamil 80mg OD Medical: 1. Daily BP monitoring and recording 2. For ophthalmologic examination Wellness: 1. Compliance with medications 2. Recommend DASH diet and avoidance of organ meats, sardines, mussels 3. At least 8 glasses of water a day 4. Reading newspaper daily 5. Increase activities of daily living Psychosocial: 2.Encourage involvement with neighbors

16 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index Patient Diagnosis Latest Lab Results and Medications Plans SANCHEZ Address: 1855 Sulu St., Sampaloc, Manila Mini Nutritional Assessment At risk for malnutrition (score 21) Geriatric Depression Scale Normal (score 5) Mini Mental State Exam No impairment (score 27) Bilaterally Extended Launching Family Breadwinner Filemon Sanchez, Jr. (Son) Decision maker Filemon Sanchez, Jr. (Son) Filemon Sanchez Male 70 y/o DM type 2, controlled, s/p BKA, right (2008) SAH St. 1, controlled Tinea versicolor, upper back Venous Insufficiency, Left foot Tobacco addiction r/o Lung CA Amlodipine 5mg OD Metformin 500mg OD Medical: 1. Daily BP and CBG monitoring and recording and daily foot examination 2. Referral to DM center for glucometer calibration 3. For yearly ophthalmologic and serum creatinine examination and HbA1c and FLP every 3-6 months 4. Suggest shift to ACE inhibitor 5. Ketoconazole 2% shampoo as a body wash 6. For Duplex ultrasound of lower extremities and pelvis 7. For chest x-ray (PA, L views) 8 Smoking cessation counselling 9. Referral to Rehabilitation Medicine 10. Update immunizations (influenza, pneumococcus, tetanus) Wellness: 1. Recommend DASH diet 2. For daily home exercises once with prescription from Rehabilitation Medicine 3. Strict compliance with medications 4. Reading newspaper daily 5. Wear loose fitting clothing and avoid sweating Psychosocial: 1. Encourage involvement with friends who don’t smoke

17 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans SOLIONGCO Address: 1114 Carola st. Sampaloc, Manila Mini-Nutritional Assessment Not at risk for malnutrition (score 12) Geriatric Depression Scale Normal (score 2) Mini Mental State Exam No impairment (score 28) Unilaterally extended Family in later life Breadwinner Juliet Soliongco (daughter-in-law) Decision Maker Juliet Soliongco (daughter-in-law) Aurora Soliongco Female 95 y/o SAH St.II controlled Senile cataract, OU Bronchial Asthma, not in acute exacerbation Telmisartan HCl (Pritor Plus) 500mg/tab ODHS Medical: 1. Daily BP monitoring and recording 2. Referral to Ophthalmology for baseline eye exam and evaluation of cataracts 3. Update immunizations (influenza, pneumococcus, tetanus) Wellness: 1.Recommend DASH diet 2.Strict compliance with medications 3. Education on avoidance of airborne allergens, air pollutants and irritants 4. Daily reading of newspaper as able Psychosocial: 1.Encourage her current involvement in social barangay groups 2. Encourage current level of ADLs performed because it enhances her feeling of self worth

18 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans DELA CRUZ Address: 1035 Miguelin St. Sampaloc, Manila Mini-Nutritional Assessment Not at risk for malnutrition (score:12) Geriatric Depression Scale: Normal (score:2) Mini Mental State Exam: Mild impairment (score: 23) Unilaterally Extended Family in later years Breadwinner Eugenia Dela Cruz (sister-in- law) Decision maker Eugenia Dela Cruz (sister-in- law) Librada Dela Cruz Female 79y/o HPN st.II controlled ASHD, CAD NIF, Chronic Stable Angina Class IIB Osteoarthritis Metoprolol 100mg/tab 1 tab ODHS Trimetazidine 35mg/tab 1 tab BID Imidapril 5mg/tab 1 tab OD ISDN 5mg/tab 1 tab prn for chest pain Clopidogrel 75mg/tab 1 tab ODHS Digoxin (Lenoxin) 250mg/tab 1tab OD Celecoxib 200mg/tab 1 tab prn for pain Omeprazole 20mg/tab 1tab OD Medical: 1. Daily BP monitoring and recording 2. Screening for gastritis during family visits 3. Update immunization (influenza, pneumococcal, tetanus) 4. For yearly ophthalmologic examination Wellness: 1.Continue strict compliance with medications 2. Recommend DASH diet 3. Encourage to drink 8-10 glasses of water daily 3. Educate patient and relatives on the signs of drug toxicity 4. Encourage daily reading of papers 5. Encourage ADL as tolerated only Psychosocial 1.Sharing of responsibilities in taking care of patient 2.Encourage good and healthy relationship with family members and peers

19 Family Information & Assessment Tools Family type & Life Cycle stage Roles and Functions Index PatientDiagnosis Latest Lab Results and Medications Plans QUEROL Address: 1089 Don Quijote St. Sampaloc Manila Contact No Mini-Nutritional Assessment: Malnourished (previous diagnosis) Geriatric Depression Scale: Can not be assessed Mini Mental State Exam: Can not be assessed Nuclear Family Family in later years Breadwinner Salud Querol Decision maker Salud Querol Caregiver Salud Querol Remedios Querol Female 85 y/o SAH St.II, uncontrolled DM type II, controlled Gouty Arthritis Malnourished Amlodipine 10 mg/tab 1 tab OD Allopurinol 300mg/tab 1 tab OD Amiodarone 200mg/tab 1 tab OD Clopidogrel 75mg/tab 1 tab OD Medical 1. Daily BP and blood glucose monitoring and recording 2. Suggest serum creatinine 3. Screening for gastritis during family visits 4. Follow-up with physician 5. Update immunizations (influenza, pneumococcus, tetanus) Wellness 1. Compliance with medications 2. Recommend DASH diet and diet low in organ meats, sardines, processed foods 3. Recommend Ensure two glasses daily and drinking glasses of water daily 5. Educate patients on benefit of healthy living and seeking to improve one’s health *patient’s relatives repeatedly refuse family visit because patient is sleeping or because is tired. Recommend discharge of patient


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