Family Medicine Case Presentation

Unbreakablea Family Medicine Case PresentationAbad, Imperial, Javate, Palma, R. Uy, ValenciaASMPH 2012ObjectivesTo discuss the family profile of Pradel familyTo establish the family diagnosis using family assessment toolsTo present a case of trauma secondary to a vehicular accidentTo discuss the impact of vehicular trauma to a familyTo briefly discuss the road safety and legal issues pertinent to the caseThe Index CaseIndex Case ProfileMP17 years oldFemaleOccidental MindoroChief ComplaintAbdominal painConsultation and Admission:December 11, 20105Vehicular AccidentNOI: Vehicular Crash (Motorcycle vs Tricycle; Motorcycle vs Truck)TOI: 2:30pmDOI: December 8, 2010POI: San Jose, Occidental Mindoro

Primary SurveyAirway: PatentBreathing: RR = 26bpm Symmetric chest expansion and clear breath sounds (-) dyspneaCirculation: HR = 94bpm (-) neck veins (-) murmursDisability: (-) sensory or motor deficits GCS:15 E4,V5,M6 although irritable and uncooperativePupils 2-3mm EBRTLExposure: Contusions, both eyes. Abrasion, chin. Hematoma, lateral forearms

Secondary SurveySigns and SymptomsAbdominal pain (3 days PTA, after VC): diffuse, cramping and sharp pain; 8 10 / 10; Aggravated by palpationAllergies: noneMedications: nonePertinent Past Medical History: (-) previous hospitalizations / surgeriesLast Oral Intake: more than one dayEvents leading to the incident

Events leading to the incident3 days PTCReturning a motorcycle she borrowedWearing a helmetGoing fast, attempted to overtakeLast motorcycle to overtake, sidesweptOff-balance, veered to opposite laneCrashed head-on to a decelerated truckSaid to have been unconsciousNo witnesses available on interviewReliability of father = 75%

Events after the incidentBrought to a nearby hospital in MindoroAdmitted, but family opted to transfer to a better facility2 days PTCAdmitted at Batangas General HospitalCranial CT was said to be unremarkableSubcapsular hematoma, liverLipase: 2000+Advised ICU stay, but patient was uncooperative

Events after the incident1 day PTCTransferred to Paranaque Doctors Hospital Family opted transfer to EAMCTransfer to SMPCH

Past Medical History: Sepsis (11 days old)Family history:Asthma motherDM - grandmotherSocial history: College studentClaims (-) smoking, drinking, drugsActive in church (Born Again)

Physical ExaminationConscious, irritable, not in cardiorespiratory distressBP: 110 / 70 mmHgTemp: 36HR: 94RR: 26

Physical ExaminationSkinbrown skin color, good turgor, no rashes, multiple abrasionsHEENT(+) periorbital hematoma, bilateral with edema, anicteric sclerae, pink palpebral conjunctiva, no TPC, no CLADPulmonarySymmetric chest expansion, clear breath sounds, no rales, no wheezes, (+) tachypneicCardiovascularAdynamic precordium, apex beat at 5th ICS LMCL, NRRR, distinct S1 S2, no murmurs

Physical ExaminationAbdomen Flat abdomen, hypoactive BS, no masses, no organomegaly (+) direct tenderness all quadrants, (+) involuntary guardingGenitourinaryNo CVA tendernessExtremities(+) Hematoma, forearm bilateral, no cyanosis, no edema, full and equal pulses

Clinical ImpressionMultiple injuries secondary to vehicular crashAcute surgical abdomen secondary to blunt abdominal trauma secondary to vehicular crashMedical and Surgical ManagmentAdmitted; IVF, NGT, Foley CatheterEmergency Explore LaparotomyEvacuation of hemoperitoneumLigation of bleedersReactive AppendicitisAppendectomyPancreatitis secondary to traumaICUCefuroxime / Metronidazole / ImipenemOmeprazole / Ketorolac / Vitamin K

Family Assessment ToolsFamily ProfileName of Family MemberRelation to PatientAge/SexOccupationMPPatient17 / FCollege SophomoreGPMother39 / FHousewifeJPFather47 / MBakerJPYounger brother15 / MHigh school seniorKPYoungest brother12 / MHigh school freshman 5 7Diabetes MellitusPRADEL FAMILYMultiple injuries secondary to vehicular crashFamily GenogramFamily Life CycleFamily with adolescents Family MapAPGARMP patientGP motherJP fatherADAPTATIONAkoy nasisiyahan dahil sa nakakaasa ako ng tulong sa aking pamilya.222PARTNERSHIPAkoy nasisiyahan sa paraaang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema.222GROWTHAkoy nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa mga bagong landas para sa aking ikauunlad.221AFFECTIONAkoy nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pag-ibig.222RESOLVEAkoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isat isa.222OVERALL ASSESSMENT10109The patient and the parents, who are directly involved in the critical matters of the patient having been admitted and suffering from a traumatic accident, are still highly functional.

8-10 highly functional

23SCREEMPARAMETERRESOURCEPATHOLOGYSocialGood relationship between family members, neighbors and fellow church members

Social activities of family are mainly church-relatedNoneCulturalFamily is very proud to be a Filipino with no intention to leave the country.

Family encourages children to participate in social welfare and church related activitiesNoneReligiousFamily is a religious Born-again Christian who devoutly respects the traditions of their church.

Family takes pride that their children are very active in church groups both in school and in their local parish

Fellow parishioners love offering is the primary source of financial support of the family at the momentNoneSCREEMPARAMETERRESOURCEPATHOLOGYEconomicFamily is usually self-sufficient, not dependent on other people for moneyFinancial problems hitting the family because of MPs vehicular accident.

Concerns by the father about the hopes and dreams of his other children who still wish to finish their primary schooling, and to continue on to future graduate coursesEducationalParents are not college graduates themselves but they strongly encourage their children to finish their education.

Family as a whole understands the value of educationContinuation of schooling as a consequence of the expenditures they will incur at the end of the medical admission.MedicalFamilys view of health as an important aspect in the general well-being of their everyday lives help with preventing them from getting and developing some predisposed diseases

Familys first and foremost concern is for MP to get well, even to the extent of spending beyond their means to avail of medical services in Metro ManilaFinancial problems limit the family from giving MP the best possible medical care.DiscussionVehicular AccidentType of illness: acute severeThe greater the severity, the greater the stressLack of emotional preparationLack of financial preparationIllness brings out the best, but may also surface pre-existing dysfunctions

Impact of Illness to the Family Stage I - Onset of IllnessStage II - Reaction to DiagnosisStage III - Major Therapeutic EffortsStage IV - Early Adjustment to OutcomeStage V - Adjustment to the Permanency of the OutcomeImpact of Illness to the Family Realization that their daughter sometimes disobeys themCentripetalFamily drawn closer together despite physical distanceBelief SystemsLove offerings from fellow parishionersGod is good to usFamily Resiliency and Coping MechanismsAdaptability Hard work and cooperationForgiveness

Individuals, families, and communities form a dynamic support system against the inevitable stresses of life

"Family Resiliency: Building Strengths to Meet Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 .

Influences of Resilience

"Family Resiliency: Building Strengths to Meet Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 .

Resiliency and the IndividualFrom an early age, individuals learn resilient behavior at home and in their communities.Overall, the childrens health and success in school, relationships, and jobs correlated with:their disposition, intelligence, communication skills, and internal locus of controlparental warmth and support, and positive relationships with siblings or other adultsand support systems in school, church, or community clubs that rewarded competence and provided a value system."Family Resiliency: Building Strengths to Meet Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 .

Resiliency and the FamilyFamilies that learn how to cope with challenges and meet individual needs are more resilient to stress and crisis. Healthy families solve problems with cooperation, creative brainstorming, and openness to others.Social support and connectedness (vs isolation) contributes to family resiliency."Family Resiliency: Building Strengths to Meet Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 .

Family Adjustment and Adaptation Response Model (FAAR)used to explain how families react to and manage change. Adjustment phase Adaptation phase.The Family Adjustment Phase

35Adjustment Phase StepsPeriod preceding a family stressor event Prior strains produce changed family demandspoor communication hardships economic circumstances Family appraises the relationship between their existing resources to adjust to the change before defining the stressor event Deciding upon a plan to manage the new situation

Adjustment Phase StepsFamilies experience either stress (positive) or distress (negative) when they conclude that the situation is either unpleasant or undesirable. The family will respond in one of three ways. Avoid, deny or ignore the stressor and its resultant demands hoping it will resolve itselfEliminate the demands by changing the stressor or altering its definitionAccept the demands of the stressor and make changes accordingly (assimilation).The first two actions may protect the family unit by minimizing the changes required,HOWEVER, they are more likely to lead to maladjustment. While assimilation may involve the reallocation of resources it is most likely to result in a satisfactory outcome or nonadjustment.In many cases, the period of adjustment is viewed as a short term response that isadequate to manage change, transitions and demands. However there are times whenthe adjustment processes are insufficient and a crisis (x) results.37The Family Adaptation PhaseThe occurrence of a crisis is not a signal that the family has failed or is dysfunctional.The adaptation phase is characterized by the familys recognition of the need to make change Modifying established rules, roles, goals and/or patterns of interaction. Occur in two distinct levels.RestructuringConsolidationLevel 1: Restructuring

Level 1: RestructuringOne or more family members become aware of an inability to meet the combination of established and new demands (the pile up or aA factor). They share an understanding of the problem (cC) and have a realistic view of the availability of resources (bB). They are able to agree on and implement solutions that influence the familys transition through the phase. Ex. using resources to solve problems, correctly appraising and accurately defining the situation families are able to maximize the solutions available.The familys problem-solving efforts and structural changes are aimed at:management of specific demandschanges to accommodate demandsrestoring organization and stability to the family unit.the pile up or aA factor

realistic view of the availability of resources (bB).

understanding of the problem (cC)

Level 2: Consolidation

Level 2: ConsolidationAfter initiating change that results in some restructuring. This may involve such things as a previously unemployed family member obtaining paid work or a change of residence. Focus is on attempting to mold the family into a coherent unit.One or more family members become aware of the family having made significant change. Attempt to facilitate a shared family awareness + acceptance of the restructuring. Success at this level involves all members of the family unit.Changes are implemented (by trial and error) in the action phase. Level 2: ConsolidationSynergizing: familys attempt to coordinate and pull together as a unit Interfacing: Acknowledging interactions between the family and community when attempting to redefine their role Needs and resources with community needs and resources is critical for successful adaptation Compromising: A realistic appraisal of family circumstances and a willingness to accept a less than perfect solution. System maintenance relies upon optimal levels of morale and esteem of family members.

Legal &Road Safety IssuesLegal Violations Underage/unlicensed driving of a borrowed motorcycle (P750 penalty to driver

Allowing an unlicensed person to drive MV (P750 penalty to owner)

Road Safety Issues Unskilled & unlicensed driver Risk to self Risk to others Speeding and overtaking (risk taking behavior) prompted accident

Philippines as of 2009, around 3.2 million to be exact, are motorcycles, scooters, or tricycles, according to the Land Transportation Office (LTO).

The WHO's Manila-based Regional Office for the Western Pacific said in an April 2007 report that young motorbike riders make up a significant percentage of injuries and fatalities among road users in the region.Speeding, the non-use of helmets, risk-taking behavior, and drunk-driving contribute to a significant portion of the motorcycle accidents.

the MMARAS said motorcycles have the highest fatality accident rate (29.46% of the total fatal accidents) compared to other vehicles. For non-fatal incidents, motorcycles also had the highest rate (6,677 or a 36.78% share) compared to cars (4,543 or 25.02%) and other vehicles (2009)45Conclusion and RecommendationsConclusionMP suffered an acute and severe illnessThe Pradel family is highly functional and resilientPoverty may limit the family from giving MP the best possible treatmentThe familys religious affiliations provide good support system

Family Healthcare PlanFamily MemberScreening TestsImmunizations/ChemoprophylaxisLifestyle ModificationCounseling NeedsMPScreen for possible psychiatric morbidities from the traumaScreen for other medical problems as a consequence of the vehicular accidentTetanus toxoid, Influenza shots and other prophylaxis Reduce stress levels, exercise, and refocusing on studies.Debriefing from the traumatic incident that caused her to be admitted and operated on

Awareness about her risk-taking behavior and legal violations that brought about the traumatic accidentGPGlucose tolerance tests and blood pressure monitoring for possible DM and HPNInfluenza shots and other prophylaxis Daily exercise, Refocus on taking care of daughter while still being admitted to the hospitalFamily counseling relating to feelings about the financial burdens of the medical costs from the accidentFamily Healthcare PlanFamily MemberScreening TestsImmunizations/ChemoprophylaxisLifestyle ModificationCounseling NeedsJPNone indicatedNone indicated. As needed.Maintain good activity in work, and in keeping up relations with the family members despite the working hoursFamily counseling relating to feelings about the financial burdens of the medical costs from the accident

Exploration of feelings regarding his wifes disagreement with him wanting to work abroad for better payJPNonePediatric immunizations as indicatedContinue focus on studies despite financial constraintsNone KPNonePediatric immunizations as indicatedContinue focus on studies despite financial constraintsNone The End

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