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Family Case Presentation Family Case Presentation University of the Philippines – Philippine General Hospital Department of Family and Community Medicine.

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Presentation on theme: "Family Case Presentation Family Case Presentation University of the Philippines – Philippine General Hospital Department of Family and Community Medicine."— Presentation transcript:

1 Family Case Presentation 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 I.Index Case Profile II.The Family III.Family Wellness Plan IV.Journal

4

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

6 Uncontrolled Blood Pressure

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

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

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

10 Levothyroxine (Thyrax) 150 mcg OD Amlodipine (Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID Amlodipine (Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID Compliance ? ASYMPTOMATIC Usual BP = 140/90 Highest BP = 160/100 Usual BP = 140/90 Highest BP = 160/100

11 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 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

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

14 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 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 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 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 General: Conscious, coherent, not in cardiorespiratory distress BP: 140/80HR: 66 RR: 18Temp: 36.7 Wt: 78 kgHt: 157 cmBMI: 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 5 th 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 General: Conscious, coherent, not in cardiorespiratory distress BP: 140/80HR: 66 RR: 18Temp: 36.7 Wt: 78 kgHt: 157 cmBMI: 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 5 th 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 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 5/5 100% ++100% ++ MOTORSENSORY DTR

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

19 Dianostics – 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 Dianostics – 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 Non-pharmacologic – Low fat, low salt diet – Daily exercise (brisk walking 30 mins OD) – BP Diary Advised follow up to PMD Advised Ophtha Consult Non-pharmacologic – 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 Genogram Type of Family Family Identification Stage in the Family Life Cycle Timeline II. Family Psychodynamics Mapping Family Psychosocial Data APGAR SCREEM

23

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

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

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 Kuya Chito finished 3 rd 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. Social History

34 Kim is a 2 nd 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. Social History

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 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. Community Neighborhood

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

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

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

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

50 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. Psychosocial Data

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. A 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. A 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. A 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 Source: Ate Edith Who lives in your home?How do you get along? NameRelationshipAgeSex ChitoBrother38M KimNiece13F WellFairlyPoor Family APGAR II

56 SCREEM

57 ResourcePathology 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 ResourcePathology 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 ResourcePathology 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 ResourcePathology 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 40 th 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 )

61 ResourcePathology 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 ResourcePathology Economic Ate Edith is satisfied with present economic condition; “Hindi kami nagigipit at may sobra pa nga.”

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

64 ResourcePathology 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 ResourcePathology 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 ResourcePathology 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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