Family Group

Family GroupNovember 2009

Family nameAddress and Telephone

number

Type of Family

Life cycle stage

Role and Functions

Index Patient Diagnosis Latest Lab Results and Medications

Plans

LOMOHAN

939 Dos Castillas St. Sampaloc, Manila

#0908 5204944

Mini-Nutrirional Assessment: malnourished

Unilaterally extended

Family in later life

1.BreadwinnerMary Jane (daughter)

2.Decision makerLourdes Lomohan (wife)

3. 1˚ CaregiverLourdes Lomohan (wife)

4.MCSIMadalas- 3Minsan- 3Halos hindi- 4

Fernando Lomohan

Male

64 y/o

s/p CVA, R MCA (June 2008)

HPN st.II controlled

Amlodipine 5mg/tab 1 tab OD

Aspirin 80mg/tab 1 tab OD pc

Multivitamins 1 tab OD

Medical:1.Update immunization (pneumococcal, influenza, tetanus) 2.Daily BP monitoring 3.Maintain good personal hygiene

Rehabilitative:1.Passive ROM exercises c/o caretakers2. Refer to Rehab Med for PT

Wellness:1.Encourage diet rich in protein, low salt, high fiber (green leafy vegetables, citrus fruits)2.Strict compliance with medications3.Ensure 2 glasses and encourage 8 glasses of water a day

Psychosocial:1.Seek and maintain personal interests (listening to the radio, reading the newspaper, watching TV)2.Encourage involvement with friends


number

Type of Family Life cycle

stage

Role and Functions


Plans

LOPEZ

957 Dos Catillas St. Sampaloc, Manila

# 7313224

Mini-Nutrirional Assessmentmalnourished


Family in later years

1.BreadwinnerEden Lopez (wife)

2.Decision makerEden Lopez (wife)

3. 1˚ CaregiverEden Lopez (wife)

4.MCSIMadalas- 1Minsan- 10Halos hindi- 1

Dominador Lopez

Male

76 y/o

Parkinson’s disease

s/p tracheostomy

s/p PEG insertion

Biperidine 2mg OD

Levodopa/Carbidopa 200/50mg/tab 1 tab OD

Multivitamins 1 tab OD

Acetylcytsteine prn

Medical:1.Continue strict compliance with medications2.Regular follow up3.Maintain position that provides optimum ventilation4.Continue strict turning schedule to avoid bed sore formation5.Perform passive ROM exercises6. Suctioning of secretions from tracheostomy tube as needed 7.Asepsis and anti sepsis technique in handling and cleaning tracheostomy tube and PEG

Wellness:1.Continue vitamin supplementation2. Ensure two glasses daily

Psychosocial1.Sharing of responsibilities in taking care of patient


number


stage

Role and Functions


Plans

SAN PEDRO

965 Adelina St. Sampaloc Manila

Phone # 735-6775

Mini- Nutritional assessment:: not at risk for malnutrition

GDS - normal

MMSE-

Extended

Life Cycle Stage

1.BreadwinnerBeatriz San Pedro

2.Decision makerMagdalena Amoranto (sister)

Beatriz San Pedro

Female

83 y/o

Hypertension St. I, controlled

Bronchial asthma, NIAE

Osteoarthritis, both knees

Hypothyroidism s/p total thyroidectomy (1988)

s/p CVA (2004)

Vitamin B Complex OD

Nifedipine 20 mg OD

Levothyroxine 100 mg OD

Cilostazol 50 mg BID

Calcium BID

Simvastatin 40 mg ½ tab OD

Medical1. Continue present medications2. BP monitoring3. Follow-up with physician4. Refer to Rehab5. Vaccination (Pneumococcal, Tetanus, Influenza)

Wellness1. Advice balanced diet, with low fat, low salt, high fiber diet (green leafy vegetables and citrus fruits)2. Encourage to drink 8-10 glasses of water daily3. Educate patients on benefit of healthy living and seeking to improve one’s health4. Multivitamins 1 tab OD


number


stage

Role and Functions


Plans

SAN PEDRO

965 Adelina St. Sampaloc Manila

# 735-6775

Nutritional assessment:not at risk for malnutrition

GDS- normal

MMSE

Extended 1.Breadwinnerself

2.Decision makerSelf

Magdalena San Pedro-Amoranto

female

79 y/o

St. II, controlled

Cataract s/p EOL,OS

Felodipine 5mg/tab, 1 tab BID

Medical1. Continue medications2. BP monitoring3. Vaccination (Tetanus, Influenza, Pneumococcal)

Wellness1. Advice balanced diet, with low fat, low salt, high fiber diet (green leafy vegetables, citrus fruits)2. Encourage to drink 8-10 glasses of water daily3. Educate patients on benefit of healthy living and seeking to improve one’s health


number


stage

Role and Functions


Plans

ROSALES

Address1070 Don Quijote St. Sampaloc, Manila Phone #

Nutritional assessment:At risk of malnutrition

Blended

Life Cycle StageLaunching Family

1.BreadwinnerTeresita Rosales

2.Decision makerGenaro Rosales

3. CaregiverLauro

4.MCSI

Jerry Rosales

Gender:Male

Age:53 y/o

DM type 2

SAH Stage 1, controlled

CKD sec to DM nephropathys/p AKA, L secondary to Diabetic foot

Amlodipine 5mg/tab OD

Amlodipine 10mg/tab OD

Acarbose 50mg/tab TID

HN 18 ‘u’/SC pre-BF and 8 ‘u’/SC pre dinner

Medical1. Assure of compliance with medications 2. Assure of compliance with thrice a week hemodialysis3. Regular follow-ups

Wellness1.Strict compliance to diet provided by physician/ dietician2.Suggest improvement of home ventilation3.Regular BP monitoring4.Annual Lipid profile/Renal profile/Cardiac profile5.Annual Ophthalmologic consult

Psychosocial1.Suggest involvement in social groups2.Encourage more outdoor activities


number

Type of Family

Life cycle stage

Role and Functions


Plans

Cudal

1016 Eloisa St. Sampaloc Manila

#735-7539

Mini-Nutritional Assessment Score: at risk of malnutrition

GDS: cannot be assessed

MMSE: cannot be assessed

Communal

Family in Later life

1. Breadwinner: Dra. Efegenia Soliven- daughter who is living in the USA

2. Decision-maker: Dra. Efegenia Soliven- daughter who is living in the USA

3. 1˚ Caregiver: Cecilia Cabais

4.MCSIMadalas-2Minsan-5Halos hindi-4

Cudal, Dorothea

Female

97 y/o

Dementia

Hearing Loss, AU

s/p hip replacement (2004)

Multivitamins, 1 tab OD

Calcium Carbonate, 1 tab BID

Medical1. Continue Multivitamins and Calcium2. Osteoporosis screening3. Maintain low salt and low fat diet4. Encourage passive ROM exercises

Psychosocial1. 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.


number

Type of Family

Life cycle stage

Role and Functions


Plans

Miguel

1016 Eloisa St.Sampaloc Manila

#735-7539

Mini-Nutritional Assessment Score: not at risk

GDS:

MMSE:

Communal

Family in Later years

1. Breadwinner : Lydia Miguel

2. Decision maker: Lydia Miguel

3. Caregiver: none

*Patient owns the house and rents it to boarders. It is her source of income.

Miguel, Lydia60/F

SAH Stage II, poorly controlled

Atenolol (Therabloc) 50mg, 1 tab OD


Folic Acid, 1 tab OD

Medical1. 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.

Psychosocial1. 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.


number

Type of Family

Life cycle stage

Role and Functions


Plans

LANOT

1134 Prudencio St. Sampaloc Manila

#0907 162 8213

Mini Nutritional Assessment Score:

GDS & MMSE: cannot be assessed


Family in Later years

1. Breadwinner : Susan Lanot (daughter)

2. Decision maker: Susan Lanot – daughter

3. 1˚Caregiver: Bella (informal caregiver)


Lanot, Anicia

Female

76 y/o

Diabetes Mellitus 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, resolving

Metoprolol 50mg/tab, 1 tab BID

Amlodipine 5mg/tab, 1 tab OD

Insulin 26 U am and 14 U pm

Medical1. Continue current medications2. Daily BP monitoring 3. Glucose monitoring TID4. Follow-up referral to ENT (hearing loss) and Ophthalmology (blurring of vision).

*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.

5. Encourage passive ROM exercises by caregiver

Psychosocial1. Maintain good interpersonal relationship with caregivers and relatives in the household


number

Type of Family

Life cycle stage

Role and Functions


Plans

LABRADOR

930 Quezon Blvd St. Sampaloc Manila

#0921-7802097

Mini Nutritional Assessment Score: at risk

GDS:

MMSE:



1. Breadwinner: Virgilio Jacob (son-in-law)2. Decision maker: Angelita Jacob (daughter)

3. Primary Caregiver: Angelita Jacob (daughter)


Labrador, Luciana

Female

76 y/o

Alzheimer's disease

Xerosis


Medical1.Continue MVP2.Update immunizations: Pneumococcal, Influenza, Tetanus3.Fall precaution4.For Osteoporosis screening

Psychosocial1. Maintain good interpersonal relationship with her daughter and her family.


number

Type of Family

Life cycle stage

Role and Functions


Plans

VICTORIA

948 Adelina St. Sampaloc, Manila

# 735 1459

Mini Nutritional Assessment Score: at risk

GDS: normal

MMSE:

Nuclear


1. Breadwinner: Supina Victoria (Daughter in law)

2. Decision maker: Supina Victoria

3. Primary Caregiver: none

Victoria, Beatriz

Female

85 y/o

SAH stage II, poorly controlledGouty 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.

Medical1.Continue current medications2.MVP, 1 tab OD3.For Ophthalmology referral (blurring of vision not fully corrected by glasses)4.Update immunization (Pneumococcal, tetanus, Influenza)

Psychosocial1.Smoking cessation2.Improve relationship with her daughter –in-law and her siblings.3.Proper budgeting


number

Type of Family

Life cycle stage

Role and Functions


Plans

RALLOS

940 Quezon Blvd. Sampaloc Manila

#704-5083

Mini Nutritional Assessment Score:

GDS: 7 (suggests depression)

MMSE:

Nuclear

Family with adolescents

1. Breadwinner: Romeo Rallos

2. Decision maker: Romeo Rallos

3. Primary Caregiver:Madeline Rallos (wife)

MCSI: Madalas-Minsan-Halos Hindi-

Family gets monthly disability pension.

Rallos, Romeo

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.

Medical1.Continue current medications2.MVP, 1 tab OD3.For Ophthalmology referral – baseline evaluation of Dm complications4.Update immunization (Pneumococcal, tetanus, Influenza)5.Labs: BUN, crea, HBA1C

Psychosocial1.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


number

Type of Family

Life cycle stage

Role and Functions


Plans

GRAVANSOS

1041 Adelina St. Sampaloc Manila Phone #

GDS: normalMMSE: cannot be fully assessed

Extended

Life Cycle StageLaunching Family

1.BreadwinnerZaldy, Polly, Myrna

2.Decision makerZaldy

3. CaregiverEmployed by patients daughter Myrna

MCSI:Madalas :0Minsan: 9Halos hindi 1

Soledad Gravansos

Female

79 y/o

Parkinson’s disease

Psychosocial problems

Biperidine (Akineton) 2mg/tab BID

MedicalContinue present medicationsVaccination (Influenza, Tetanus, Pneumococcal)Multivitamins 1 tab ODRefer to neurology

WellnessAdvice balanced diet, with low fat, low salt, high fiber diet Encourage to drink 8-10 glasses of water dailyIncrease oral fluid intakeEncourage to ambulate (w/assistance) Educate patient on benefit of healthy living and seeking to improve one’s health

Psychosocialcaregiver-focused social support

Encourage good and healthy relationship with family members and peers

Encourage each family member to spend quality time with the patient


number

Type of Family

Life cycle stage

Role and Functions


Plans

LAGANZUA 1209 A.J. Barlin St Sampaloc, Manila Phone #

Nutritional assessment:

GDS-normal


Life Cycle StageFamily in later years

1.Breadwinner:patient

2.Decision maker:patient

3. Caregiver:Meann Laganzua

MCSI:Madalas: 2Minsan: 1Halos Hindi: 8

Flora Laganzua

Female

81 y/o

OsteoporosisFracture R hipSenile Cataract OUDextroscoliosisUnderweightPsychosocial problemsPatient currently has no caregiver

Medicines:MultivitaminsMefenamic Acid 500 mg/tabCalcium gluconate 1 tab OD

MedicalMultivitamins 1 tab ODCalcium gluconate 1 tab ODMefenamic Acid 500 mg/tabRefer to OrthopedicsRefer to RehabRefer to OphthalmologyVaccination – Tetanus, Pneumococcal, InfluenzaFor hypertensive work-up

WellnessAdvice balanced diet, with low fat, low salt, high fiber diet Encourage to drink 8-10 glasses of water dailyEncourage to ambulate with assistance Educate patients on benefit of healthy living and seeking to improve one’s health

PsychosocialEncourage good and healthy relationship with bordersEncourage borders to spend quality time with the patient


number

Type of Family

Life cycle stage

Role and Functions


Plans

CAABAY1029 Adelina St. Sampaloc Manila Phone #493-7918

GDS-normal

Extended

Life Cycle Stage:

Launching Family

1.BreadwinnerMarlon Dela Cruz

2.Decision makerMarlon Dela Cruz

3. No Caregiver

Cristy Caabay

Female

66 y/o

Hypertension St. 2, uncontrolledt/c cataractPsychosocial problems

Losartan 100mg/tab ODAmlodipine 5mg/tab OD

MedicalContinue with present medicationsBP monitoringCBC with platelet, Urinalysis, Lipid Profile, 12L-ECG, Chest X-ray, FBSVaccination – Pneumococcal, Influenza, TetanusOphthalmology referral

WellnessAdvice balanced diet, with low fat, low salt, high fiber dietEncourage to drink 8-10 glasses of water daily Encourage to ambulate (w/assistance)Continue vitamins supplementation Educate patients on benefit of healthy living and seeking to improve one’s health

PsychosocialEncourage good and healthy relationship with family members and peers Encourage each family member to spend quality time with the patient


number

Type of Family

Life cycle stage

Role and Functions


Plans

RAGAZA

932 R. Papa St. Manila

733-1297

Mini Nutritional assessment

Total assessment 16

GDS: normal

BilaterallyExtended


Crispin Ragaza

Male

80 y/o

1. BreadwinnerMarilou

(daughter)

2. Decision-makers Crispin and Marilou

3. No caregiver

SAH stage 1, controlledMalnourished

Amlodipine 10mgtab ODMVP 1 tab OD

Medical Daily BP monitoring at health centerContinue current medicationsReferral to dietary for counseling

WellnessEnsure 2 glasses/day and low salt and low fat dietImmunizations: tetanus, influenza and pneumococcal

Psychosocial Encourage family support and daily hygiene


number

Type of Family

Life cycle stage

Role and Functions


Plans

RAGAZA

932 R. Papa St. Manila

733-1297

Mini Nutritional assessmentTotal assessment: 15

BilaterallyExtendedFamily in later life

Flaviana RagazaFemale 81 y/o

1. BreadwinnerMarilou

(daughter)2. Decision-makers Crispin and Marilou 3.CaregiverCrispin and Marilou

MCSI: Madalas:4Minsan: 4Halos hindi: 3

Alzheimer’s disease, Cataract, ODMalnourished

MVP 1 tab OD MedicalReferral to Neurology Referral to OphthalmologyReferral to dietary for counseling Wellness Ensure 2 glasses/day Immunizations: tetanus, influenza and pneumococcal

PsychosocialEncourage family support and daily hygiene


number

Type of Family

Life cycle stage

Role and Functions


Plans

RICARDO

1829B Sisa St, Sampaloc, Manila

#09272442408

Family Wellness Plan

Mini Nutritional Assessment:


Launching Family

1.BreadwinnerVivian (patient)

2.Decision makerVivian (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 + Hydrochlorothiazide 12.5mg OD

Omeprazole 20mg OD

Medical:1.Daily BP monitoring2.For 12L ECG, lipid profile, FBS3.For ophthalmologic examination

Wellness:1.Recommend light snacks every 2 hours for waking hours2. Recommend DASH diet3.Strict compliance with medications3. Reading daily

* Patient and her relatives have been refusing visits due to scheduling conflicts. Suggest discharge


number

Type of Family

Life cycle stage

Role and Functions


Plans

RICARDO

1722 Ibarra St, Sampaloc, Manila

#09194236146


Mini Nutritional Assessment

Mini Mental State Exam

Bilaterally extended

Launching Family

Breadwinnerdaughter

2.Decision makerDaughter

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 recording2.For ophthalmologic examination (offered and refused)3. Screening for peptic ulcer disease

Wellness:1.Recommend light snacks every 2 hours for waking hours2. Recommend DASH diet3.Strict compliance with medications4. Increase ADL

Psychosocial:1.Encourage involvement with friends


number

Type of Family

Life cycle stage

Role and Functions


Plans

ROFO

1726B Ibarra St, Sampaloc, Manila

#7116657




Bilaterally Extended

Family in Later Life

BreadwinnerSon in law

Decision makerSon in law

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:Daily BP monitoring and recordingFor ophthalmologic examination

Wellness:Recommend DASH diet and avoidance of organ meats, sardines, musselsAt least 8 glasses of water a day Reading dailyIncrease activities of daily living



number

Type of Family

Life cycle stage

Role and Functions


Plans

SANCHEZ

1855 Sulu St., Sampaloc, Manila



Geriatric Depression Scale


Modified Caregiver Index

Bilaterally Extended

Launching Family

BreadwinnerSon

Decision makerSon

1˚ CaregiverSon

Filemon Sanchez

Male

70 y/o

Diabetes Mellitus type 2, controlled, s/p BKA , right (2008)

SAH St. 1, controlled

Tinea versicolor, upper back

Venous Insufficiency, Left foot

Tobacco addiction

Amlodipine 5mg OD

Metformin 500mg OD

Medical:Daily BP and CBG monitoring and recording and daily foot examinationReferral to DM center for glucometer calibrationFor yearly ophthalmologic and serum creatinine examination and HbA1c and FLP every 3-6 monthsSuggest shift to ACE inhibitorKetoconazole 2% shampoo as a body washFor comprehensive Duplex ultrasoundSmoking cessation counsellingReferral to Rehabilitation Medicine

Wellness:Recommend DASH dietFor daily home exercisesStrict compliance with medicationsEducate patients on benefit of healthyReading daily

Psychosocial:Encourage involvement with friends who don’t smoke


number

Type of Family

Life cycle stage

Role and Functions


Plans

SOLIONGCO

1114 Carola st. Sampaloc, Manila

Mini-Nutrirional Assessment

Geriartric Depression Scale


Modified Caregiver Strain Index



Aurora Soliongco

Female

95 y/o


Bronchial Asthma, not in Acute Exacerbation

Telmisartan HCl (Pritor Plus) 500mg/tab ODHS

Medical:1. Continue present medications2. BP monitoring3. Avoid airborne allergens, air pollutants and irritants, cold air, streinous exercise

Wellness:1.Recommend DASH diet2.Strict compliance with medications3.Ensure 2 glasses and encourage 8 glasses of water a day



number


stage

Role and Functions


Plans

DELA CRUZ

1035 Miguelin St. Sampaloc, Manila

Mini-Nutrirional Assessment




Unilaterally Extended


1.BreadwinnerEugenia Dela Cruz (daughter-in-law)

2.Decision maker

3. 1˚ CaregiverEugenia Dela Cruz (daughter-in-law)

Librada Dela Cruz

Female

769y/o


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

Celicoxib 200mg/tab 1 tab prn for pain

Omeprazole 20mg/tab 1tab OD

Medical:1.Continue strict compliance with medications2. BP monitoring3. Follow-up with physicians

Wellness:1. Recommend DASH diet2. Encourage to drink 8-10 glasses of water daily3. Educate patients on benefit of healthy living and seeking to improve one’s health

Psychosocial1.Sharing of responsibilities in taking care of patient2.Encourage good and healthy relationship with family members and peers


number


stage

Role and Functions


Plans

QUEROL

1089 Don Quijote St. Sampaloc Manila

Tel# 731-1328

Mini-Nutritional Assessment





1.Breadwinner

2.Decision maker

3. 1˚ Caregiver

Remedios Querol

Female

85 y/o

HPN 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

Medical1. Continue present medications2. BP monitoring3. Continue CBG monitoring4. Follow-up with physician

WellnessRecommend DASH dietEnsure two glasses dailyEncourage to drink 8-10 glasses of water dailyEducate patients on benefit of healthy living and seeking to improve one’s health

Family Group

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