Presentation on theme: "Payumo, Pelayo, Quiogue, Rodriguez"— Presentation transcript:
1Payumo, Pelayo, Quiogue, Rodriguez Family Case Presentation University of the Philippines – Philippine General Hospital Department of Family and Community MedicinePayumo, Pelayo, Quiogue, Rodriguez
2Specific ObjectivesTo 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 planTo be able to formulate family wellness plansTo critically appraise a related journal article and show its application to the case/community
3OutlineIndex Case ProfileThe FamilyFamily Wellness PlanJournal
8History of Present Illness 2007Weight LossHYPERTHYROIDISMConsult at Capitol Medical CenterWork ups DoneEasy FatigabilityRAI x 1 doseLevothyroxine (Thyrax) 150 mcg ODHeat Intolerance & sweatingDifficulty Falling AsleepDysphagiaPalpitations
9History of Present Illness 200720082009Amlodipine (Norvasc) 5 mg ODMetoprolol (Neobloc) 50 mg BIDCompliance?Last follow up was on January 2009ASYMPTOMATICRegular Follow upLevothyroxine (Thyrax) 150 mcg OD
10History of Present Illness Levothyroxine (Thyrax) 150 mcg OD June 2009Amlodipine (Norvasc) 5 mg ODMetoprolol (Neobloc) 50 mg BIDASYMPTOMATICCompliance?UNCONTROLLEDLevothyroxine (Thyrax) 150 mcg ODBLOOD PRESSUREUsual BP = 140/90Highest BP = 160/100
11Review of SystemsGeneral: no weight loss, (+) weight gain, undocumented (about 30% in 2 years) no loss of appetite, no fever, no night sweatsSkin: No rash, no lumps, no dryness, no pruritus, no changes in hair or nailsHEENT: occasional diffuse headache esp during hot weather, no dizziness, blurring of vision, no tinnitus, no dysphagia, no gum/nose bleedingRespiratory: no hemoptysis, no cough, no colds, no dypneaCardiovascular: no chest pain, no palpitations, no orthopnea, no easy fatigability, no PNDGIT: no abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, no melena, no hematocheziaGUT: no dysuria, no oliguria, no hematuria, no urinary frequencyHema: no excessive bleeding, no easy bruisabilityEndocrine: no polyuria, no polyphagia, no polydipsia, no heat or cold intolerance, no excessive sweatingMSS: no myalgia, no arthralgiaNeuro: no seizures, no loss of consciousness, no paresthesias, no paralysis
12Past Medical History2008 – admitted at a clinic in San Juan for 1 day for correction of hypokalemiaNo Bronchial AsthmaNo Diabetes MellitusNo known allergiesNo PTB
13Family Medical History (+) DM – Father, sister(+) Heart Disease – Mother(+) CVD – Sister(+) HPN – Sister(-) PTB(-) Bronchial Asthma(-) liver/kidney problem
14Menstrual/Sexual/OB History Menarche at 13 yrs oldRegular Monthly Period, lasting for 3 days, use of 3-4 ppd moderately soakedOccasional dysmenorrheaNo previous sexual contactG0
15Personal and Social History High school graduateNonsmokerNonalcoholic beverage drinkerDenies illicit drug useLives with brother and nieceUnemployed, supported by a brother who works abroadDiet consists mostly of vegetables
16Physical ExaminationGeneral: Conscious, coherent, not in cardiorespiratory distressBP: 140/80 HR: 66 RR: 18 Temp: 36.7Wt: 78 kg Ht: 157 cm BMI: 31.6Skin: good skin turgor, no pallor, no cyanosisHEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no palpable cervical lymphadenopathy, distended neck veins, no thyromegalyCHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath soundsHEART: adynamic precordium, normal rate, regular rhythm, apex beat at the 5th ICS, LMCL, S1>S2 at the apex, S2>S1 at the base, no murmurABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no organomegalyEXTREMITIES: no edema, no cyanosis, full & equal pulses
17Neurologic Examination Awake, oriented to time, person and placeCranial Nerves:CN I – can smell CN VIII – can hearCN II – (+) ROR, OU CN IX, X – gag intactCN III, IV, VI – EOM intact CN XI – good shoulder shrugCN V – bicorneal reflex intact CN XII – tongue midlineCN VII – no facial asymmetry5/55/5100%100%++++5/55/5100%100%++++DTRMOTORSENSORY
18ASSESSMENT Hypertension Stage II, Uncontrolled Obese Class I S/P RAI ablation x hyperthyroidism
19PLAN Dianostics Therapeutics FBS, Urinalysis, Serum Crea, K, Lipid Profile, 12 L ECGTSHTherapeuticsShift to Losartan + HCTZ 50/ tab ODCont Levothyroxine 150 mcg 1 tab OD
20PLAN Non-pharmacologic Advised follow up to PMD Advised Ophtha Consult Low fat, low salt dietDaily exercise (brisk walking 30 mins OD)BP DiaryAdvised follow up to PMDAdvised Ophtha Consult
22Outline I. Family structure and function II. Family Psychodynamics GenogramType of FamilyFamily IdentificationStage in the Family Life CycleTimelineII. Family PsychodynamicsMappingFamily Psychosocial DataAPGARSCREEM
24ABANILLA FAMILY JULY 2009 ALFREDO, 65 (1993) CRISCENCIA, 73 (2003) CHITO38VANGIE SIGANAY41PACIFICO64MERLYN62ANGELITO56FELIPE52DIONISIO50ROGELIO48SUSAN46EDITH40JERRY35KIM13Diabetes MellitusHeart DiseaseHypertensionMild Stroke
25ABANILLA-SIGANAY FAMILY JULY 2009ABANILLASIGANAYALFREDO, 65 (1993)CRISCENCIA, 73 (2003)4PACIFICO64MERLYN62ANGELITO563 SiblingsSUSAN46EDITH40CHITO38JERRY35VANGIE413342KIM13Diabetes MellitusHypertensionHeart DiseaseMild Stroke
26Type of Family Structure: extended-family Ordinal position: third to the last childFamily socio-economic class patterns: middle-classFamily set-up: democratic
27Family Identification CompositionAte Edith: third to the youngest of 10 children
28Family Identification CompositionKuya Chito: second to the youngest in the family
29Family Identification CompositionKuya Jerry: youngest child of Abanilla family, currently in CanadaKim: 13-year-old daughter of Kuya Chito
30Family Identification Abanilla home hasone bedrooma living-room with television and stereo componenta dining area with one table,a kitchen and a sinka dirty kitchen outside with 2 chained dogs named Santino and Ampon
31Social HistoryAte 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.
32Social HistoryKuya 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.
33Social HistoryKuya 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.
34Social HistoryKim 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.
35Community 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.
36Community Neighborhood Balacbacan ResidentsThey 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.
37Family Life Line1992: 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
38Family 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.
39Family 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.
40Family 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.
43ABANILLA-SIGANAY FAMILY JULY 2009ABANILLASIGANAYALFREDO, 65 (1993)CRISCENCIA, 73 (2003)4PACIFICO64MERLYN62ANGELITO563 SiblingsSUSAN46EDITH40CHITO38JERRY35VANGIE413342KIM13
44Family 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.
45Psychosocial 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.
46Psychosocial 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.
47Psychosocial 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.
48Psychosocial Data Authority According to Ate Edith, authority is conferred mainly on Kuya Jerry.
49Psychosocial Data Primary caregiver Ate Edith is the main care-giver of the family since the wife of Kuya Chito is abroad
50Psychosocial 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.
52Family APGAR I Ate Edith total: 9 PalagiPaminsan-minsanHalos HindiAAko ay nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema.PAko ay nasisiyahan sa paraang pakikipagtalakayan sa akin ng aking pamilya tungkol sa aking problema.GAko 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.RAko ay nasisiyahan at ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.
53Family APGAR I Kuya Chito total: 9 PalagiPaminsan-minsanHalos HindiAAko ay nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema.PAko ay nasisiyahan sa paraang pakikipagtalakayan sa akin ng aking pamilya tungkol sa aking problema.GAko 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.RAko ay nasisiyahan at ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.
54Family APGAR I Kim total: 10 PalagiPaminsan-minsanHalos HindiAAko ay nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema.PAko ay nasisiyahan sa paraang pakikipagtalakayan sa akin ng aking pamilya tungkol sa aking problema.GAko 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.RAko ay nasisiyahan at ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.
55Family APGAR II Well Fairly Poor Source: Ate Edith Who lives in your home? How do you get along?NameRelationshipAgeSexChitoBrother38MKimNiece13FWellFairlyPoor
57SCREEM Resource Pathology Social --- Well-balanced lines of communication with other members of the communityAte 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.---
58SCREEM 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---
59SCREEM 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 fishTaught us Batangueno terms iibong-ibong---
60SCREEM Resource Pathology Religious Non–practicing Roman Catholic They attend mass during Sundays only about twice as yearCelebrates All Saints day, Christmas and other Holidays. Observe “pasiyam” and prayer for the dead on the 40th day of burialNo rigid religious rituals and seem to be open to new ideasDoes not observe the Lenten season (because it is the resort’s peak season)a
61SCREEM Resource Pathology Economic Main source of income is Kuya Jerry who is working abroad (Canada)Economically stable and seems to have no financial difficultiesKuya Chito also earns enough for him and Kim and his wife works in Dubai to pay for Kim’s schooling.
62SCREEM Resource Pathology Economic Ate Edith is satisfied with present economic condition; “Hindi kami nagigipit at may sobra pa nga.”
63SCREEM Resource Pathology Educational Ate Edith – high school graduate Kuya Chito – finished up to 3rd year high schoolKim is presently on her 2nd year high school and plans to pursue a degree in college---
64SCREEM 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 attainmentAte Edith and Kuya Chito have no plans to pursue their studies again.---
65SCREEM 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.
66SCREEMResourcePathologyMedicalKuya Chito and Kim rarely get sick.
68Edith Abanilla, 40 year old ScreeningDaily personal hygieneDaily BP monitoringMonthly self breast examination and annual by MDBiannual dental hygieneAnnual periodic physical examAnnual fecalysis, urinalysis, CXR, cholesterol monitoring
69Edith Abanilla Developmental monitoring Obesity and pre-menopausal counselingMental healthFamily relationshipOTC for common ailmentsSanitation issues, accident exposure and prevention
70Edith Abanilla Exercise Prescription Frequency: 3-4x per week Intensity:Target Heart Rate: (220-40)x activity=(220-40)x 0.6=108 beats/minDuration: 30 minutes/sessionType: Walking exercisesTime: Approximately 1.5 hours per week
71Edith Abanilla Diet Prescription Daily Caloric Requirements= DBW x activityDBW=(height in cm-100) – 10%= ( ) – 5.7=51.3 kg
72Edith Abanilla Diet Prescription Total Caloric Requirements= 51.3 kg x 25= cal/day= cal/dayCarbohydrates = x 0.6= cal/4= gramsCHON = x .25 = cal/4= gramsFats = x .15 = cal/9 = gramsACTUAL BODY WEIGHT – 78 kg
73Edith Abanilla Stress Maintenance of resort and land dispute In-charge of collecting electrical fees of people in BalacbacanTaking care of Kim and her studies
74Chito Abanilla, 38 year old ScreeningDaily personal hygieneAnnual BP monitoringBiannual dental hygieneAnnual periodic physical examAnnual fecalysis, urinalysis, CXRReduce alcohol intake into moderation: 1 glass/day; smoking cessation
75Chito Abanilla Developmental monitoring Weight counseling Mental healthFamily, marital relationshipOTC for common ailmentsSanitation issues, accident exposure and prevention
76Chito Abanilla Exercise Prescription Frequency: 3-4x per week Intensity:Target Heart Rate: (220-38)x activity=(220-38)x 0.6=109 beats/minDuration: 30 minutes/sessionType: Walking exercisesTime: Approximately 1.5 hours per week
77Chito Abanilla Diet prescription Daily Caloric Requirements= DBW x activityDBW=(height in cm-100) – 10%= ( ) – 6.76=60.88 kg
78Chito Abanilla Diet Prescription Total Caloric Requirements= kg x 25= 1522 cal/dayCarbohydrates = 1522 x 0.6= cal/4= gramsCHON = 1522 x .25 = cal/4= gramsFats = 1522 x .15 = cal/9 = gramsACTUAL BODY WEIGHT – 68 kg
79Chito Abanilla Stress Being far away from his wife Raising a teenage daughter
80Kim Abanilla, 13 year old Screening Daily personal hygiene Annual BP monitoringMonthly self breast examinationAnnual periodic physical examFor hearing testAnnual fecalysis, urinalysis, PPD/Direct BCG
81Kim Abanilla Developmental Monitoring Growth Chart and Nutrition Sexual DevelopmentEmotional and Mental DevelopmentParental relationshipOTC for common ailmentsSanitation issues and accident exposure
82Kim Abanilla Exercise Prescription Frequency: 3-5x per week Intensity: Target Heart Rate: (220-13)x activity=(220-13)x 0.6=124 beats/minDuration: 30 minutes/sessionType: Cardiovascular and muscle strengthening/toning exercisesTime: Approximately 2 hours per week
83Kim Abanilla Diet Prescription Daily Caloric Requirements= DBW x activityDBW=(height in cm-100) – 10%= ( ) – 5.7=51.3 kgTotal Caloric Requirements = 51.3kg x 35 = cal/dayCarbohydrates = x 0.6= cal/4 = gramsCHON = x .25 = cal/4 = gramsFats = x .15 = cal/9 = gramsActual Body Weight – 46 kg
84Kim Abanilla Stress Being far away from her mother Being in high school