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Payumo, Pelayo, Quiogue, Rodriguez

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1 Payumo, Pelayo, Quiogue, Rodriguez
Family Case Presentation University of the Philippines – Philippine General Hospital Department of Family and Community Medicine Payumo, Pelayo, Quiogue, Rodriguez

2 Specific Objectives To formulate, implement, and discuss a patient-centered health management plan. To describe the family psychodynamics using widely used family assessment tools. To discuss the social environment, its resources, and hindrances to a successful wellness plan To be able to formulate family wellness plans To critically appraise a related journal article and show its application to the case/community

3 Outline Index Case Profile The Family Family Wellness Plan Journal

4 INDEX CASE PROFILE

5 General Data Editha Abanilla 40 y.o./female Single Right-handed
Roman Catholic Unemployed Balacbacan, Laiya Aplaya, San Juan, Batangas

6 Uncontrolled Blood Pressure
Chief Complaint Uncontrolled Blood Pressure

7 History of Present Illness
2003 Consult Private MD in Batangas Work ups Done Occasional Headache HYPERTENSION Amlodipine (Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID Left Upper Extremity Numbness

8 History of Present Illness
2007 Weight Loss HYPERTHYROIDISM Consult at Capitol Medical Center Work ups Done Easy Fatigability RAI x 1 dose Levothyroxine (Thyrax) 150 mcg OD Heat Intolerance & sweating Difficulty Falling Asleep Dysphagia Palpitations

9 History of Present Illness
2007 2008 2009 Amlodipine (Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID Compliance? Last follow up was on January 2009 ASYMPTOMATIC Regular Follow up Levothyroxine (Thyrax) 150 mcg OD

10 History of Present Illness Levothyroxine (Thyrax) 150 mcg OD
June 2009 Amlodipine (Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID ASYMPTOMATIC Compliance? UNCONTROLLED Levothyroxine (Thyrax) 150 mcg OD BLOOD PRESSURE Usual BP = 140/90 Highest BP = 160/100

11 Review of Systems General: no weight loss, (+) weight gain, undocumented (about 30% in 2 years) no loss of appetite, no fever, no night sweats Skin: No rash, no lumps, no dryness, no pruritus, no changes in hair or nails HEENT: occasional diffuse headache esp during hot weather, no dizziness, blurring of vision, no tinnitus, no dysphagia, no gum/nose bleeding Respiratory: no hemoptysis, no cough, no colds, no dypnea Cardiovascular: no chest pain, no palpitations, no orthopnea, no easy fatigability, no PND GIT: no abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, no melena, no hematochezia GUT: no dysuria, no oliguria, no hematuria, no urinary frequency Hema: no excessive bleeding, no easy bruisability Endocrine: no polyuria, no polyphagia, no polydipsia, no heat or cold intolerance, no excessive sweating MSS: no myalgia, no arthralgia Neuro: no seizures, no loss of consciousness, no paresthesias, no paralysis

12 Past Medical History 2008 – admitted at a clinic in San Juan for 1 day for correction of hypokalemia No Bronchial Asthma No Diabetes Mellitus No known allergies No PTB

13 Family Medical History
(+) DM – Father, sister (+) Heart Disease – Mother (+) CVD – Sister (+) HPN – Sister (-) PTB (-) Bronchial Asthma (-) liver/kidney problem

14 Menstrual/Sexual/OB History
Menarche at 13 yrs old Regular Monthly Period, lasting for 3 days, use of 3-4 ppd moderately soaked Occasional dysmenorrhea No previous sexual contact G0

15 Personal and Social History
High school graduate Nonsmoker Nonalcoholic beverage drinker Denies illicit drug use Lives with brother and niece Unemployed, supported by a brother who works abroad Diet consists mostly of vegetables

16 Physical Examination General: Conscious, coherent, not in cardiorespiratory distress BP: 140/80 HR: 66 RR: 18 Temp: 36.7 Wt: 78 kg Ht: 157 cm BMI: 31.6 Skin: good skin turgor, no pallor, no cyanosis HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no palpable cervical lymphadenopathy, distended neck veins, no thyromegaly CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds HEART: adynamic precordium, normal rate, regular rhythm, apex beat at the 5th ICS, LMCL, S1>S2 at the apex, S2>S1 at the base, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no organomegaly EXTREMITIES: no edema, no cyanosis, full & equal pulses

17 Neurologic Examination
Awake, oriented to time, person and place Cranial Nerves: CN I – can smell CN VIII – can hear CN II – (+) ROR, OU CN IX, X – gag intact CN III, IV, VI – EOM intact CN XI – good shoulder shrug CN V – bicorneal reflex intact CN XII – tongue midline CN VII – no facial asymmetry 5/5 5/5 100% 100% ++ ++ 5/5 5/5 100% 100% ++ ++ DTR MOTOR SENSORY

18 ASSESSMENT Hypertension Stage II, Uncontrolled Obese Class I
S/P RAI ablation x hyperthyroidism

19 PLAN Dianostics Therapeutics
FBS, Urinalysis, Serum Crea, K, Lipid Profile, 12 L ECG TSH Therapeutics Shift to Losartan + HCTZ 50/ tab OD Cont Levothyroxine 150 mcg 1 tab OD

20 PLAN Non-pharmacologic Advised follow up to PMD Advised Ophtha Consult
Low fat, low salt diet Daily exercise (brisk walking 30 mins OD) BP Diary Advised follow up to PMD Advised Ophtha Consult

21 FAMILY ASSESSMENT

22 Outline I. Family structure and function II. Family Psychodynamics
Genogram Type of Family Family Identification Stage in the Family Life Cycle Timeline II. Family Psychodynamics Mapping Family Psychosocial Data APGAR SCREEM

23 FAMILY GENOGRAM

24 ABANILLA FAMILY JULY 2009 ALFREDO, 65 (1993) CRISCENCIA, 73 (2003)
CHITO 38 VANGIE SIGANAY 41 PACIFICO 64 MERLYN 62 ANGELITO 56 FELIPE 52 DIONISIO 50 ROGELIO 48 SUSAN 46 EDITH 40 JERRY 35 KIM 13 Diabetes Mellitus Heart Disease Hypertension Mild Stroke

25 ABANILLA-SIGANAY FAMILY
JULY 2009 ABANILLA SIGANAY ALFREDO, 65 (1993) CRISCENCIA, 73 (2003) 4 PACIFICO 64 MERLYN 62 ANGELITO 56 3 Siblings SUSAN 46 EDITH 40 CHITO 38 JERRY 35 VANGIE 41 3 3 4 2 KIM 13 Diabetes Mellitus Hypertension Heart Disease Mild Stroke

26 Type of Family Structure: extended-family
Ordinal position: third to the last child Family socio-economic class patterns: middle-class Family set-up: democratic

27 Family Identification
Composition Ate Edith: third to the youngest of 10 children

28 Family Identification
Composition Kuya Chito: second to the youngest in the family

29 Family Identification
Composition Kuya Jerry: youngest child of Abanilla family, currently in Canada Kim: 13-year-old daughter of Kuya Chito

30 Family Identification
Abanilla home has one bedroom a living-room with television and stereo component a dining area with one table, a kitchen and a sink a dirty kitchen outside with 2 chained dogs named Santino and Ampon

31 Social History Ate Edith graduated from Laiya National High School. She worked for 3 years in a fruit store in San Pablo. She then transferred to a grocery in Poblacion for 1 year before staying in Laiya with her brother Jerry and their niece Kim. Prior to owning a resort, they had a fishing business for 10 years. Ate Edith now busies herself with the resort and with collecting money for electricity.

32 Social History Kuya Jerry is an HRM graduate who later studied Culinary arts. He financed his studies by having his own catering business. He has lived with his sister Edith but has recently left to work in Canada as a chef. He was the one who started plans of owning a resort and now is its main financier.

33 Social History Kuya Chito finished 3rd year HS, after which he worked as a waiter in Super Ferry for 3 years. It was where he met his wife, who was then his supervisor. He later transferred to work at Kabayan resort in Laiya. He was an employee there for 10 years and recently was assigned at Kaffe Brako as a barista.

34 Social History Kim is a 2nd year HS student. She has stayed with Ate Edith and Kuya Jerry since she was a child. Her father has lived with them for 6 years now. Her mother works as a supervisor in a Makro store in Dubai; she goes home every 3 years.

35 Community Neighborhood
Sitio Balacbacan in Laiya Aplaya is home to a number of beach resorts, composed of several houses owned by common families. Fishing is the community’s main livelihood. Early morning each day, fishermen bring ashore their catch for the sitio’s consumption. As such, everyday meals usually consist of fish-based viands. A recent issue of land ownership in Balacbacan threatens its residents’ homes and livelihood.

36 Community Neighborhood
Balacbacan Residents They are usually composed of each one’s relatives, although they remain in good terms with the few people who are not related to them. They are hospitable and friendly, and are used to having visitors and tourists in their community.

37 Family Life Line 1992: Death of Ate Edith’s Father 2000: Kim’s mother left 2003: Death of Ate Edith’s Mother 2005: Island Sky Resort 2007: Relocation of People in Balacbacan June 2009: Kuya Jerry left for Canada

38 Family Life Cycle Stage
Since the three siblings share a home with Kuya Jerry’s 13-year-old daughter for the past few years, they can be said to be in the stage of transition from families with young children to families with teenagers/ adolescents. For Ate Edith and Kuya Jerry, they had adjusted their role as siblings to a role of parenting as help to their brother Kuya Chito. They shared with him the task of child rearing, in addition to financial and household tasks.

39 Family Life Cycle Stage
With Kim now developing as a teenager, the siblings must learn to be flexible regarding understanding certain changes in her. Although physical independence is not yet an issue, psychological independence may now be budding. Sex education should also be given importance, as early pregnancy in not uncommon in Laiya. Ate Edith may also be dealing with career issues, with the current threat of land ownership in Balacbacan.

40 Family Life Cycle Stage
The Abanilla family had faced their parents’ death earlier in the cycle. Thus, their concern is concentrated to their generation and the younger ones. Chronic illness, i.e., hypertension, has also become a challenge to Ate Edith, again earlier than expected in the cycle.

41 FAMILY PSYCHODYNAMICS

42 FAMILY MAP

43 ABANILLA-SIGANAY FAMILY
JULY 2009 ABANILLA SIGANAY ALFREDO, 65 (1993) CRISCENCIA, 73 (2003) 4 PACIFICO 64 MERLYN 62 ANGELITO 56 3 Siblings SUSAN 46 EDITH 40 CHITO 38 JERRY 35 VANGIE 41 3 3 4 2 KIM 13

44 Family Dynamics The Abanilla family is functional.
The Abanilla siblings meet on special occasions at Ate Edith’s house in Balacbacan. The family faced great challenges upon the death of their father, followed years after by the death of their mother. Their eldest sibling became their leader and they coped with death as a family. Ate Edith’s home is now composed of her, Kuya Chito and his daughter Kim, and Kuya Jerry. They have a good relationship and currently have no source of conflict.

45 Psychosocial Data Communication patterns
The Abanilla family’s communication style can be said to be receptive, occasionally with some distancing. The siblings’ separate family lives sometimes make it difficult for them to ask/give help from/to each other. Ate Edith’s home in Balacbacan is more of the receptive type, as Kuya Jerry finds time to regularly talk to them although he is currently in Canada.

46 Psychosocial Data Leadership
This role belongs to the family’s eldest, Kuya Pacifico. Age is a factor here. It was their Kuya Pacifico who helped the family cope with their parents’ death.

47 Psychosocial Data Breadwinner
This role is shared by Ate Edith, who manages their resort, and Kuya Jerry, who now works in Canada as a chef. They also help with financing Kim’s studies.

48 Psychosocial Data Authority
According to Ate Edith, authority is conferred mainly on Kuya Jerry.

49 Psychosocial Data Primary caregiver
Ate Edith is the main care-giver of the family since the wife of Kuya Chito is abroad

50 Psychosocial Data Family’s present priorities
Maintenance of the resort and their corresponding land ownership is the family’s main priority, especially with the current issue in Balacbacan regarding property rights.

51 FAMILY APGAR

52 Family APGAR I Ate Edith total: 9 
Palagi Paminsan-minsan Halos Hindi A Ako ay nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema. P Ako ay nasisiyahan sa paraang pakikipagtalakayan sa akin ng aking pamilya tungkol sa aking problema. G Ako ay nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa bagong landas para sa aking ikauunlad. Ako ay nasisiyahan sa paraang ipinadarama ng aking pamilya ang kanilang pagmamahal at nauunawaan nila ang aking damdamin katulad ng galit, lungkot, at pag-ibig. R Ako ay nasisiyahan at ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.

53 Family APGAR I Kuya Chito total: 9 
Palagi Paminsan-minsan Halos Hindi A Ako ay nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema. P Ako ay nasisiyahan sa paraang pakikipagtalakayan sa akin ng aking pamilya tungkol sa aking problema. G Ako ay nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa bagong landas para sa aking ikauunlad. Ako ay nasisiyahan sa paraang ipinadarama ng aking pamilya ang kanilang pagmamahal at nauunawaan nila ang aking damdamin katulad ng galit, lungkot, at pag-ibig. R Ako ay nasisiyahan at ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.

54 Family APGAR I Kim total: 10 
Palagi Paminsan-minsan Halos Hindi A Ako ay nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema. P Ako ay nasisiyahan sa paraang pakikipagtalakayan sa akin ng aking pamilya tungkol sa aking problema. G Ako ay nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa bagong landas para sa aking ikauunlad. Ako ay nasisiyahan sa paraang ipinadarama ng aking pamilya ang kanilang pagmamahal at nauunawaan nila ang aking damdamin katulad ng galit, lungkot, at pag-ibig. R Ako ay nasisiyahan at ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.

55 Family APGAR II Well Fairly Poor 
Source: Ate Edith Who lives in your home? How do you get along? Name Relationship Age Sex Chito Brother 38 M Kim Niece 13 F Well Fairly Poor

56 SCREEM

57 SCREEM Resource Pathology Social ---
Well-balanced lines of communication with other members of the community Ate Edith is the main electricity collector in Balacbacan. Ate Edith usually spends time in the afternoon in her brother’s house. She lives in a neighborhood full of their relatives. Ate Edith loves watching television especially telenovelas. Ate Edith sometimes plays badminton with her niece in their backyard. ---

58 SCREEM Resource Pathology Social
Kuya Chito has a set of good friends in Site with whom he spends time. Kim likes spending time with her best friend, Vanessa. Kim usually spends her time studying during weekdays and watches the television during weekends. Each member of the family is free to pursue on his/her chosen activities ---

59 SCREEM Resource Pathology Cultural
The Abanilla family are proud Batanguenos. They are proud of the beach and the beautiful mountains in Aplaya. They said that Batanguenos are “mababait”. Offer us fish like tamban, and Ate Edith’s homemade dried fish Taught us Batangueno terms iibong-ibong ---

60 SCREEM Resource Pathology Religious Non–practicing Roman Catholic
They attend mass during Sundays only about twice as year Celebrates All Saints day, Christmas and other Holidays. Observe “pasiyam” and prayer for the dead on the 40th day of burial No rigid religious rituals and seem to be open to new ideas Does not observe the Lenten season (because it is the resort’s peak season) a

61 SCREEM Resource Pathology Economic
Main source of income is Kuya Jerry who is working abroad (Canada) Economically stable and seems to have no financial difficulties Kuya Chito also earns enough for him and Kim and his wife works in Dubai to pay for Kim’s schooling.

62 SCREEM Resource Pathology Economic
Ate Edith is satisfied with present economic condition; “Hindi kami nagigipit at may sobra pa nga.”

63 SCREEM Resource Pathology Educational Ate Edith – high school graduate
Kuya Chito – finished up to 3rd year high school Kim is presently on her 2nd year high school and plans to pursue a degree in college ---

64 SCREEM Resource Pathology Educational
Members of the family had adequate education such that most of the problems encountered were settled satisfactorily. Not burdened by inadequate educational attainment Ate Edith and Kuya Chito have no plans to pursue their studies again. ---

65 SCREEM Resource Pathology Medical
The Abanilla family has a good health seeking behavior. Health care is easily available since the barangay health center is just a walk away and the BHWs are familiar to them, especially that they have relatives who are BHWS. Ate Edith goes to Poblacion or Capitol for her medical check –up.

66 SCREEM Resource Pathology Medical Kuya Chito and Kim rarely get sick.

67 Family Wellness Plan

68 Edith Abanilla, 40 year old
Screening Daily personal hygiene Daily BP monitoring Monthly self breast examination and annual by MD Biannual dental hygiene Annual periodic physical exam Annual fecalysis, urinalysis, CXR, cholesterol monitoring

69 Edith Abanilla Developmental monitoring
Obesity and pre-menopausal counseling Mental health Family relationship OTC for common ailments Sanitation issues, accident exposure and prevention

70 Edith Abanilla Exercise Prescription Frequency: 3-4x per week
Intensity: Target Heart Rate: (220-40)x activity =(220-40)x 0.6 =108 beats/min Duration: 30 minutes/session Type: Walking exercises Time: Approximately 1.5 hours per week

71 Edith Abanilla Diet Prescription
Daily Caloric Requirements= DBW x activity DBW=(height in cm-100) – 10% = ( ) – 5.7 =51.3 kg

72 Edith Abanilla Diet Prescription
Total Caloric Requirements= 51.3 kg x 25= cal/day = cal/day Carbohydrates = x 0.6= cal/4= grams CHON = x .25 = cal/4= grams Fats = x .15 = cal/9 = grams ACTUAL BODY WEIGHT – 78 kg

73 Edith Abanilla Stress Maintenance of resort and land dispute
In-charge of collecting electrical fees of people in Balacbacan Taking care of Kim and her studies

74 Chito Abanilla, 38 year old
Screening Daily personal hygiene Annual BP monitoring Biannual dental hygiene Annual periodic physical exam Annual fecalysis, urinalysis, CXR Reduce alcohol intake into moderation: 1 glass/day; smoking cessation

75 Chito Abanilla Developmental monitoring Weight counseling
Mental health Family, marital relationship OTC for common ailments Sanitation issues, accident exposure and prevention

76 Chito Abanilla Exercise Prescription Frequency: 3-4x per week
Intensity: Target Heart Rate: (220-38)x activity =(220-38)x 0.6 =109 beats/min Duration: 30 minutes/session Type: Walking exercises Time: Approximately 1.5 hours per week

77 Chito Abanilla Diet prescription
Daily Caloric Requirements= DBW x activity DBW=(height in cm-100) – 10% = ( ) – 6.76 =60.88 kg

78 Chito Abanilla Diet Prescription
Total Caloric Requirements= kg x 25= 1522 cal/day Carbohydrates = 1522 x 0.6= cal/4= grams CHON = 1522 x .25 = cal/4= grams Fats = 1522 x .15 = cal/9 = grams ACTUAL BODY WEIGHT – 68 kg

79 Chito Abanilla Stress Being far away from his wife
Raising a teenage daughter

80 Kim Abanilla, 13 year old Screening Daily personal hygiene
Annual BP monitoring Monthly self breast examination Annual periodic physical exam For hearing test Annual fecalysis, urinalysis, PPD/Direct BCG

81 Kim Abanilla Developmental Monitoring Growth Chart and Nutrition
Sexual Development Emotional and Mental Development Parental relationship OTC for common ailments Sanitation issues and accident exposure

82 Kim Abanilla Exercise Prescription Frequency: 3-5x per week Intensity:
Target Heart Rate: (220-13)x activity =(220-13)x 0.6 =124 beats/min Duration: 30 minutes/session Type: Cardiovascular and muscle strengthening/toning exercises Time: Approximately 2 hours per week

83 Kim Abanilla Diet Prescription
Daily Caloric Requirements= DBW x activity DBW=(height in cm-100) – 10% = ( ) – 5.7 =51.3 kg Total Caloric Requirements = 51.3kg x 35 = cal/day Carbohydrates = x 0.6= cal/4 = grams CHON = x .25 = cal/4 = grams Fats = x .15 = cal/9 = grams Actual Body Weight – 46 kg

84 Kim Abanilla Stress Being far away from her mother
Being in high school

85 JOURNAL APPRAISAL

86 THANK U!


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