FAMILY MEDICINE
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Transcript of FAMILY MEDICINE
Mid-Course ReportDecember 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
BreadwinnerMary Jane (daughter)
Decision makerLourdes Lomohan (wife)
1˚ CaregiverLourdes Lomohan (wife)
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
Family nameAddress and Telephone
number
Type of Family
Life cycle stage
Role and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
LOPEZ
957 Dos Catillas St. Sampaloc, Manila
# 7313224
Mini-Nutrirional Assessmentmalnourished
Unilaterally extended
Family in later years
BreadwinnerEden Lopez (wife)
Decision makerEden Lopez (wife)
1˚ CaregiverEden Lopez (wife)
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
Family nameAddress and Telephone
number
Type of Family
Life cycle stage
Role and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
SAN PEDRO
965 Adelina St. Sampaloc Manila
Phone # 735-6775
Mini- Nutritional assessment:: not at risk for malnutrition
GDS - normal
MMSE- normal
Extended
Life Cycle Stage
BreadwinnerBeatriz San Pedro
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
Family nameAddress and Telephone
number
Type of Family
Life cycle stage
Role and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
SAN PEDRO
965 Adelina St. Sampaloc Manila
# 735-6775
Mini- Nutritional assessment score:not at risk for malnutrition
GDS- normal
MMSE- normal
Extended Breadwinnerself
Decision makerSelf
Magdalena San Pedro-Amoranto
female
79 y/o
HPN 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
Family nameAddress and Telephone
number
Type of Family
Life cycle stage
Role and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
ROSALES
Address1070 Don Quijote St. Sampaloc, Manila
Mini-Nutritional assessment:At risk of malnutrition
Blended
Life Cycle StageLaunching Family
BreadwinnerTeresita Rosales
Decision makerGenaro Rosales
1° CaregiverLauro
MCSI
Jerry Rosales
Male
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
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
CUDAL
Address: 1016 Eloisa St. Sampaloc Manila
Contact No.735-7539
Mini-Nutritional Assessment ScoreAt risk of malnutrition
Mini Mental State ExamCan not be assessed
Geriatric Depression ScaleCan not be assessed
Communal
Family in Later life
Breadwinner Dra. Efegenia Soliven(daughter living abroad)
Decision-makerDra. Efegenia Soliven(daughter living abroad)
1˚ Caregiver Cecilia Cabais (informal caregiver) MCSI Madalas-2 Minsan-5 Halos hindi-4
Dorothea Cudal
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 Calcium
Wellness1. Dietary advise- eat more vegatebles, fruits, eggs, drink milk and other fruit drinks. 2. 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.
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
MIGUEL
Address:1016 Eloisa St.Sampaloc Manila
Contact No.735-7539
Mini-Nutritional Assessment ScoreNot at risk
Geriatric Depression ScaleNot assessed-patient was in Ilocos
Communal
Family in Later years
Breadwinner Lydia Miguel
Decision maker Lydia Miguel
*Patient owns the house and rents it to boarders. It is her source of income.
Lydia Miguel
Female
60 y/o
SAH Stage II, poorly controlled
Atenolol (Therabloc) 50mg, 1 tab OD
Multivitamins, 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.
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
LANOT
Address1134 Prudencio St. Sampaloc Manila
Contact No.09071628213
Mini-Nutritional Assessment ScoreNot at risk
Mini Mental State ExamNormal
Geriatric Depression ScaleNormal
Unilaterally extended
Family in Later years
Breadwinner Susan Lanot (daughter)
Decision maker Susan Lanot (daughter)
1˚ Caregiver Florabel Teodoro (neice) MCSI Madalas-1 Minsan-1 Halos hindi-9
Anicia Lanot
Female
76 y/o
DM 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 secondary to gastric ulcer, resolved (2008)
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)5. Screening for gastritis with every family visit6. Encourage passive ROM exercises by caregiver
*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.
Psychosocial1. Maintain good interpersonal relationship with caregivers and relatives in the household
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
LABRADOR
Address930 Quezon Blvd St. Sampaloc Manila
Contact No0921-7802097
Mini Nutritional AssessmentAt risk for malnutrtion
Geriatric Depression Scalecannot be fully assessed
Mini Mental State Examcannot be fully assessed
Unilaterally extended
Family in Later life
Breadwinner Virgilio Jacob (son-in-law)
Decision maker Angelita Jacob (daughter)
1 Caregiver Angelita Jacob (daughter) MCSI Madalas-1 Minsan-4 Halos hindi-6
Luciana Labrador,
Female
76 y/o
Alzheimer's disease
Xerosis
Multivitamins, 1 tab OD
Medical1.Continue MVP
Wellness1. Maintain a balance diet2. Update immunizations: (Pneumococcal, Influenza, Tetanus)3. Fall precaution4. For Osteoporosis screening
Psychosocial1. Maintain good interpersonal relationship with her daughter and her family.
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
VICTORIA
Address948 Adelina St. Sampaloc, Manila
Contact No735 1459
Mini Nutritional AssessmentAt risk for malnutrition
Mini Mental State ExamNormal
Geriatric Depression ScaleNormal
Nuclear
Family in Later life
BreadwinnerSupina Victoria (daughter in law)
Decision MakerSupina Victoria (daughter in law)
Beatriz Victoria
Female
85 y/o
SAH stage II, poorly controlled
Gouty 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)
Wellness1. Maintain balance diet2. Update immunization (Pneumococcal, tetanus, Influenza)
Psychosocial1.Smoking cessation2.Improve relationship with her daughter –in-law and her siblings.3.Proper budgeting
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
RALLOS
Address940 Quezon Blvd. Sampaloc Manila
Contact No704-5083
Mini Nutritional AssessmentNot at risk
Mini Mental State ExamNormal
Geriatric Depression ScaleSuggests depression
Nuclear
Family with adolescents
BreadwinnerRomeo Rallos
Decision makerRomeo Rallos
1 CaregiverMadeline Rallos
(wife) MCSI Madalas-1 Minsan-1 Halos Hindi-9
*Family getsmonthly disabilitypension.
Romeo Rallos
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.For BUN, serum creatinine, HBA1C
Wellness1.Update immunization (Pneumococcal, tetanus, Influenza)
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
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
RAGAZA
Address: 932 R. Papa St. Manila
Contact No:733-1297
Mini Nutritional AssessmentMalnourished
BilaterallyExtended
Family in later life
BreadwinnerMarilou Ragaza(daughter)
DecisionmakersMarilou Ragaza(daughter)
CaregiverMarilou Ragaza(daughter) MCSI Madalas:4 Minsan: 4 Halos hindi: 3
Flaviana Ragaza
Female
81 y/o
Alzheimer’s disease
Senile cataract, OD
Malnourished
MVP 1 tab OD Medical1. Referral to Neurology 2. Referral to Ophthalmology3. Referral to dietary for counseling
Wellness1. Ensure 2 glasses/day 2. Update immunizations (tetanus, influenza and pneumococcal)3. Encourage proper hygiene
Psychosocial1. Encourage family support for cataract surgery
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
RAGAZA
Address:932 R. Papa St. Manila
Contact No733-1297
Mini Nutritional AssessmentMalnourished
Geriatric Depression ScaleNormal
BilaterallyExtended
Family in later life
BreadwinnerMarilou Ragaza(daughter)
DecisionmakersMarilou Ragaza(daughter)
Crispin Ragaza
Male
80 y/o
SAH stage 1, controlled
Malnourished
Amlodipine 10mgtab OD
MVP 1 tab OD
Medical 1. Daily BP monitoring at health center2. Continue current medications3. Referral to dietary for counseling
Wellness1. Ensure 2 glasses/day and low salt and low fat diet2. Update Immunizations (tetanus, influenza and pneumococcal)
Psychosocial1. Encourage family support and daily hygiene
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
LAGANZUA Address1209 A.J. Barlin St Sampaloc, Manila
Mini Nutritional AssessmentAt risk for malnutrition
Geriatric Depression ScaleNormal
Unilaterally extended
Life Cycle StageFamily in later years
BreadwinnerFlora Laganzua
Decision makerFlora Laganzua
1 CaregiverNone
Flora Laganzua
Female
81 y/o
Osteoporosis
Fracture R hip
Senile Cataract OU
Dextroscoliosis
Underweight
Psychosocial problems*Patient currently has no caregiver
Multivitamins 1 tab OD
Mefenamic Acid 500 mg/tab
Calcium gluconate 1 tab OD
Medical1. For hypertensive work-up2. Refer to Orthopedics3. Refer to Rehab4. Refer to Ophthalmology5. Update vaccination (Tetanus, Pneumococcal, Influenza)
Wellness1. Advise balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily3. Encourage to ambulate with assistance 4. Educate patientson benefit of healthy living and seeking to improve one’s health
Psychosocial1. Encourage good and healthy relationship with borders2. Encourage borders to spend quality time with the patient
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
GRAVANSOS
Address:1041 Adelina St. Sampaloc Manila
Mini Mental State ExamCan not be assessed
Geriatric Depression ScaleNormal
Extended
Launching Family
BreadwinnerZaldy, Polly, Myrna
Decision makerZaldy
CaregiverEmployed by patients daughter Myrna MCSI Madalas :0 Minsan: 9 Halos hindi 1
Soledad Gravansos
Female
79 y/o
Parkinson’s disease
Psychosocial problems
Biperidine (Akineton) 2mg/tab BID
Medical1. Continue present medications2. Update vaccination (Influenza, Tetanus, Pneumococcal)3. Refer to neurology4. Suggest Multivitamins 1 tab OD
Wellness1. Advice balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water dailyIncrease oral fluid intake3. Encourage to ambulate (w/assistance) 4. Educate patient on benefit of healthy living and seeking to improve one’s health
Psychosocial1. Caregiver-focused social support2. Encourage good and healthy relationship with family members and peers3. Encourage each family member to spend quality time with the patient
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
CAABAY
Address1029 Adelina St. Sampaloc Manila
Contact No493-7918
Geriatric Depression ScaleNormal
Extended
Launching Family
BreadwinnerMarlon Dela Cruz
Decision makerMarlon Dela Cruz
Cristy Caabay
Female
66 y/o
SAH St. 2, uncontrolled
t/c Senile Cataract
Psychosocial problems
Losartan 100mg/tab OD
Amlodipine 5mg/tab OD
Medical1. Continue with present medications2. Daily BP monitoring and recording3. For: CBC with platelet, Urinalysis, Lipid Profile, 12L-ECG, Chest X-ray, FBS4. Update vaccination (Pneumococcal, Influenza, Tetanus)5. For referral to Ophthalmology
Wellness1. Advice balanced diet, with low fat, low salt, high fiber diet2. Encourage to drink 8-10 glasses of water daily 3. Encourage to ambulate w tih assistance4. Continue vitamins supplementation5. Educate patients on benefit of healthy living and seeking to improve one’s health
Psychosocial1. Encourage good and healthy relationship with family members and peers2. Encourage each family member to spend quality time with the patient
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
RICARDO
Address:1829B Sisa St, Sampaloc, Manila
Contact No.09272442408
Mini Nutritional AssessmentNot at risk for malnutrtion (previous diagnosis)
Mini Mental State ExamCan not be assessed
Geriatric Depression ScaleCan not be assessed
Unilaterally extended
Launching Family
BreadwinnerVivian (patient)
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’s relatives have been refusing visits due to scheduling conflicts. The patient is only available at 4am and 10pm due to her work. Suggest discharge
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
RICARDO
Address1722 Ibarra St, Sampaloc, Manila
Contact No09194236146
Mini Nutritional AssessmentNot at risk (score 12)
Mini Mental State ExamMild Impairment(score 23)
Geriatric Depression ScaleNormal (score 5)
Bilaterally extended
Family in later years
BreadwinnerRosario Castillo (Daughter)
Decision makerRosario Castillo (Daughter)
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 gastritis symptoms with every family visit
Wellness:1.Recommend light snacks every 2 hours for waking hours2. Recommend DASH diet3.Strict compliance with medications4. Increase ADL5. Encourage daily reading of newspapers
Psychosocial:1.Encourage more ocial involvement with neighbors
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
ROFO
Address:1726B Ibarra St, Sampaloc, Manila
Contact No.7116657
Mini Nutritional AssessmentNot at risk (score 14)
Mini Mental State ExamMild impairment (score 27)
Geriatric Depression ScaleNormal (score 3)
Bilaterally Extended
Family in Later Life
BreadwinnerEdna Garcia (daughter)
Decision makerEdna Garcia (daughter)
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:1. Daily BP monitoring and recording2. For ophthalmologic examination
Wellness:1. Compliance with medications2. Recommend DASH diet and avoidance of organ meats, sardines, mussels3. At least 8 glasses of water a day 4. Reading newspaper daily5. Increase activities of daily living
Psychosocial:2.Encourage involvement with neighbors
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient
Diagnosis Latest Lab Results and Medications
Plans
SANCHEZ
Address: 1855 Sulu St., Sampaloc, Manila
Mini Nutritional AssessmentAt risk for malnutrition (score 21)
Geriatric Depression ScaleNormal (score 5)
Mini Mental State ExamNo impairment (score 27)
Bilaterally Extended
Launching Family
BreadwinnerFilemon Sanchez, Jr. (Son)
Decision makerFilemon Sanchez, Jr. (Son)
Filemon Sanchez
Male
70 y/o
DM type 2, controlled, s/p BKA , right (2008)
SAH St. 1, controlled
Tinea versicolor, upper back
Venous Insufficiency, Left foot
Tobacco addiction
r/o Lung CA
Amlodipine 5mg OD
Metformin 500mg OD
Medical:1. Daily BP and CBG monitoring and recording and daily foot examination2. Referral to DM center for glucometer calibration3. For yearly ophthalmologic and serum creatinine examination and HbA1c and FLP every 3-6 months4. Suggest shift to ACE inhibitor5. Ketoconazole 2% shampoo as a body wash6. For Duplex ultrasound of lower extremities and pelvis7. For chest x-ray (PA, L views)8 Smoking cessation counselling9. Referral to Rehabilitation Medicine 10. Update immunizations (influenza, pneumococcus, tetanus)
Wellness:1. Recommend DASH diet2. For daily home exercises once with prescription from Rehabilitation Medicine3. Strict compliance with medications4. Reading newspaper daily5. Wear loose fitting clothing and avoid sweating
Psychosocial:1. Encourage involvement with friends who don’t smoke
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
SOLIONGCO
Address:1114 Carola st. Sampaloc, Manila
Mini-Nutritional AssessmentNot at risk for malnutrition (score 12)
Geriatric Depression Scale Normal (score 2)
Mini Mental State ExamNo impairment (score 28)
Unilaterally extended
Family in later life
BreadwinnerJuliet Soliongco (daughter-in-law)
Decision MakerJuliet Soliongco (daughter-in-law)
Aurora Soliongco
Female
95 y/o
SAH St.II controlled
Senile cataract, OU
Bronchial Asthma, not in acute exacerbation
Telmisartan HCl (Pritor Plus) 500mg/tab ODHS
Medical:1. Daily BP monitoring and recording2. Referral to Ophthalmology for baseline eye exam and evaluation of cataracts3. Update immunizations (influenza, pneumococcus, tetanus)
Wellness:1.Recommend DASH diet2.Strict compliance with medications3. Education on avoidance of airborne allergens, air pollutants and irritants4. Daily reading of newspaper as able
Psychosocial:1.Encourage her current involvement in social barangay groups2. Encourage current level of ADLs performed because it enhances her feeling of self worth
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
DELA CRUZ
Address:1035 Miguelin St. Sampaloc, Manila
Mini-Nutritional AssessmentNot at risk for malnutrition (score:12)
Geriatric Depression Scale: Normal (score:2)
Mini Mental State Exam:Mild impairment(score: 23)
Unilaterally Extended
Family in later years
BreadwinnerEugenia Dela Cruz (sister-in-law)
Decision makerEugenia Dela Cruz (sister-in-law)
Librada Dela Cruz
Female
79y/o
HPN st.II controlled
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
Celecoxib 200mg/tab 1 tab prn for pain
Omeprazole 20mg/tab 1tab OD
Medical:1. Daily BP monitoring and recording2. Screening for gastritis during family visits3. Update immunization (influenza, pneumococcal, tetanus)4. For yearly ophthalmologic examination
Wellness:1.Continue strict compliance with medications2. Recommend DASH diet3. Encourage to drink 8-10 glasses of water daily3. Educate patient and relatives on the signs of drug toxicity4. Encourage daily reading of papers5. Encourage ADL as tolerated only
Psychosocial1.Sharing of responsibilities in taking care of patient2.Encourage good and healthy relationship with family members and peers
Family Information & Assessment
Tools
Family type &
Life Cycle stage
Roles and Functions
Index Patient Diagnosis Latest Lab Results and Medications
Plans
QUEROL
Address:1089 Don Quijote St. Sampaloc Manila
Contact No.731-1328
Mini-Nutritional Assessment: Malnourished (previous diagnosis)
Geriatric Depression Scale: Can not be assessed
Mini Mental State Exam:Can not be assessed
Nuclear Family
Family in later years
BreadwinnerSalud Querol
Decision makerSalud Querol
Caregiver Salud Querol
Remedios Querol
Female
85 y/o
SAH 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. Daily BP and blood glucose monitoring and recording2. Suggest serum creatinine 3. Screening for gastritis during family visits4. Follow-up with physician5. Update immunizations (influenza, pneumococcus, tetanus)
Wellness1. Compliance with medications2. Recommend DASH diet and diet low in organ meats, sardines, processed foods3. Recommend Ensure two glasses daily and drinking 8-10 glasses of water daily5. Educate patients on benefit of healthy living and seeking to improve one’s health
*patient’s relatives repeatedly refuse family visit because patient is sleeping or because is tired. Recommend discharge of patient