Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina
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Transcript of Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina
Baslar, IsaBelmonte, CelesteBrillante, Christie
Bulatao, JoseCheng, Monina
Family Case Presentation
GENERAL OBJECTIVE
To present a patient with osteoporosis, Fracture, Right hip
SPECIFIC OBJECTIVESTo identify medical, psychological, social and
economic problems of the index patient and his family
To analyze the family 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
GENERAL DATA
F. L. 81 years old female Roman Catholic Filipino Single Store owner DOB:4/23/28
HISTORY OF PRESENT ILLNESS
CONSULT
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
PERSONAL & SOCIAL HISTORYNon-smokerNon-alcoholic beverage drinkerDenies illicit drug use
Diet: Mixed diet (vegetables, fruits, meat)Store owner, retired teacherBS Education graduateDoes household chores, goes to churches and
market
PAST MEDICAL HISTORY
Malaria in 1938 (10 yrs old)-treated by a family physician
(?) Hypertensive since 2005, with BP elevations of SBP 130-140/ DBP 80-90.
No DM, No Asthma, no PTBNo operations(+) allergy to medicolImmunization: Unrecalled
FAMILY HISTORY
(-) asthma (-) allergy (-)PTB (+)Kidney disease – sister (+) HPN – sister (-) DM (-) Cancer
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 36.7C• 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
PHYSICAL EXAMINATION• CHEST: symmetrical chest expansion, no retraction,
clear breath sounds• HEART: adynamic precordium, regular rhythm, apex
beat at 5th 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
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
DTR’s: ++ on all extremities Sensory: No sensory deficit No Babinski reflex No nuchal rigidity, Brudzinski sign, Kernig’s sign
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
Clock Drawing Test Geriatric Depression Scale: 3 (normal)
ASSESSMENT OF INDEX PATIENT
OsteoporosisFracture, R hipSenile Cataract, OUDextroscoliosis
FAMILY ASSESSMENT
UST
DAPITANP. N
OVAL BARLIN ST
ELOISA ST
ADELIN
A ST
X
STAIRS
PATIENT’S ROOM
CR
PATIENT’S BED
TV
CABINET
CHAIRCHAIR
E.FAN
TABLE
WIN
DO
WS
ENVIRONMENTAL HISTORYConcrete type, 2-storey buildingHouse-rented patient rents 8 bedrooms (patient occupies only one room and
rents the others)Fairly Clean , well-ventilated and well-litElectricity from MeralcoWater source from NAWASA but drinking water - purified waterToilet Type- flush, Drainage is goodRegular waste disposal, no segregation but regularly collectedDo not have pets but there are many stray animals and pests in
the neighborhoodArea is accessible by- taxi, jeep, tricycle
FAMILY TREE- Laganzua Family
Lorenza,81
Jose,30
Adelaida, 27 Andrea,22 Jesus,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 , 72 Inocencia,100
Family Structure• Type of Family- Unilaterally extended• Ordinal Position: Third• Social Class Pattern : Low Income Family• Family Set-Up: Democratic
FAMILY PROFILE
AGE/SEX
RELATION TO HEAD
EDUCATIONAL ATTAINMENT
OCCUPATION CURRENT HEALTH STATUS
Flora 81/F Aunt B.S. Education graduate
Retired teacher, store owner
OsteoporosisFracture, R hipSenile Cataract, OUDextroscoliosis
Me-Anne 33/F Wife 2nd year- B.S. Computer Science
Housewife Arachnoid cyst(?), s/p spine surgery (June 2009)
Ariel 31/M Head B.S. Nursing Nurse in San Lazaro
Essentially Normal
Seth 6/M Son Prep student Asthma
FAMILY LIFELINE• 2002- Ariel and MeAnne were married and
rented a room beside Flora’s• 2003- Seth was born• 2007- Seth started Nursery school• 2009-
– (Jan) Flora had a fall which caused hip fracture– (June) MeAnne was diagnosed with a spine cyst and
was operated
ECONOMIC PROFILEIncome PhP 22,000Expenses
FOOD 10,000 EDUCATION 3,000 MEDICATION 1,000 MISCELLANEOUS
(electricity, water, house rent) 4,000__ TOTAL EXPENSES: 18,000Savings: 4,000
Alloc ation of inc ome
F oodE ducationMedicationmiscellaneous
HIGHLY FUNCTIONAL
FAMILY APGAR Flora Laganzua Me-anne Laganzua
1. Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema.
2 2
2. Ako’y nasisiyahan sa paraan ng pakikipag-usap sa akin ang aking pamilya tungkol sa aking problema.
2 1
3. Ako’y nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas para sa aking ikauunlad
2 2
4. Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pagibig.
2 1
5. Ako’y nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isa’t-isa.
1 2
TOTAL (Interpretation: 8-10 highly functional, 4-7 moderately dysfunctional, <4 severely dysfunctional) SCALE: 2-Palagi, 1-Paminsan-minsan, 0-Halos hindi
9 8
PARAMETER STRENGTH WEAKNESSSOCIAL [ / ] Open intrafamilial lines of
communication[ / ] Absence of animosity/rivalry[ / ] Healthy/supportive intrafamilial relationships[ / ] Healthy/supportive extrafamilial relationships
[ ] Lack of intrafamilial lines of communication[ ] Presence of animosity/rivalry[ ] Unhealthy intrafamilial relationships[] Unhealthy 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.)
[ ] Presence of some beliefs/practices that are unacceptable to our culture or negatively affect way of living (Specify these practices):
RELIGIOUS [ / ] Spirituality is positively influencing way of life[ / ] Practicing one’s faith, enduring because of his faith
[ ] Spirituality is negatively or not at all influencing way of life[ ] Not practicing one’s faithOthers: Religious activity is not a significant aspect of their family life
PARAMETER STRENGTH WEAKNESS
EDUCATIONAL [ / ] Level of education is not a hindrance to achievement, livelihood, success[ / ] Level of education facilitates comprehension of most challenging circumstances
[ ] Level of education is a hindrance to achievement, livelihood, success[ ] Level of education hinders comprehension of most challenging circumstances
ECONOMIC [ / ] Ability to allocate funds appropriately[ / ] Ability to make ends meet most of the time
[ ] Inability to allocate funds appropriately[ ] Inability to make ends meet most of the time
MEDICAL [ / ] Good compliance with medical management[ ] Timely and appropriate medical consultation[ / ] Aware and practices wellness and environmental sanitation.
[ ] Poor compliance with medical management[ /] Inappropriate medical consultation[ ] Not aware / does not practice wellness and environmental sanitation
MODIFIED CAREGIVER STRAIN INDEX
Me-anne Laganzua• Madalas- 2• Minsan – 1 • Halos Hindi - 8
FAMILY LIFE CYCLE STAGE
Family with young children- starts with pregnancy for the 1st child to emergence of adolescents.
FIRST ORDER CHANGE1. Supplying adequate space , facilities and equipment for the
expanding family2. Meeting predictable and unexpected costs of family life with
small children3. Sharing responsibilities within the extended family and
between members of the growing family4. Maintaining mutually satisfactory sexual relationship and
planning for the future children5. Creating and maintaining effective communication system in
the family6. Cultivating the full potentials of relationship with relatives
within the extended family7. Tapping resources, serving needs, and enjoying contracts
outside the family8. Facing dilemmas and reworking philosophies
.
. .
.
.
SECOND ORDER CHANGE
1. Accepting marital system to make space for children
2. Taking on parenting role3. Re-alignment of relationship with
extended family to include parenting and grandparenting roles
.
.
.
FAMILY ASSESSMENT
Family with young children – UNILATERALLY EXTENDED
STAGE IN THE ILLNESS TRAJECTORY
STAGE V: • Adjustment to the permanency
of the outcome.
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
FAMILY HEALTH CARE PLAN: Index Patient
TYPE OF CARE PROBLEM RECOMMENDATIONSWELLNESS {promotive, preventive}
Patient maintains a balanc dietLast immunization: unrecalled
For immunization: Tetanus, Pneumococcal, InfluenzaEncourage ROM exercises daily
MEDICAL Osteoporosis with Fracture , R hip Senile Cataract, OUWith episodes of BP elevations
For Rehabilitation therapyFor orthopaedic consultFor Ophthalmologic consultFor Hypertensive work-up
PSYCHOSOCIAL Patient 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.
FAMILY HEALTH CARE PLAN: Other family members
TYPE OF CARE FAMILY MEMBER
PROBLEM RECOMMENDATIONS
WELLNESS {promotive, preventive}
Me-AnneArielSeth
Maintain balance dietUpdate immunizationDaily exercise
MEDICAL Me-Anne
Seth
s/p spine surgery for arachnoid cyst(?) June 2009Asthma- last attack unrecalled
For ff-up with Neurology
Avoid triggers
PSYCHOSOCIAL Me-Anne Stopped 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.