Transcript LEC 7 Family Medicine Case

LEC 7 Family Medicine Case
Asuncion, Dalman, Doromal, Dy,
Generoso, Mejia, Ong
Purpose
• To identify interventions to help in developing
a healthier biopsychosocial environment for a
neglected child
• Points to focus on
– the progression of the patient’s disease
– the reasons for inadequate treatment
– the personal and social history of the patient
History
Identifying data
• PT, 12 or 13 years old, male
• Residing in Ilugin Phase 1, a “magbabasura”
accdg to neighbors
• Highest educational attainment: grade 1
• Roman Catholic, social class D-E
• Came in on foot, with mother and younger
sister
Chief complaint
• “masakit ang malaking daliri ng paa” (pain at
the big toe)
• Concern of the main caretaker: patient is
having fever episodes already, and they are
scared of what may happen if the condition
persists
History of Present illness
• 2 days PTC – the patient hit the plantar aspect of
his right big toe on a rock, with the development
of a wound
– With immediate sharp pain (7/10), and with pain
when pressure is applied
– Still able to walk, but with a limp
– Developed undocumented intermittent high grade
fever relieved by paracetamol, associated with
productive cough (whitish phlegm) and colds
• Persistence prompted consult at Ilugin
Community Center
Review of Systems
• General: with body malaise
• HEENT: no head ache, no dizziness, no blurring of
vision, no epistaxis, no dysphagia
• Cardiopulmonary: no chest pain, no dyspnea, no
hemoptysis, no palpitations
• GI: no abdominal pain, no change in bowel habits,
feces color brown and formed, no vomiting, no
hematemesis
• Genitourinary: no dysuria, no hematuria
• Neurological: no loss of consciousness
• Extremities: no muscle/joint pains
Past Medical History
• No previous hospitalizations
– A few episodes of diarrhea, fever and cough in the
past (uncertain time)
• No previous surgeries
Immunizations history
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BCG
2 DPT
2 OPV
3 HEPA B
1 Measles
HEADSSS
• Home
– Patient lives in a depressed area with mother and
3 more siblings.
– Mother is a freelance laundrywoman, step-father
is a stay-in construction worker
– House is only composed of 1 room same size as
classroom 301 in ASMPH, with only 3 walls (1 side
does not have a wall), no electricity, no water, no
mosquito nets. House has a roof (metal sheets)
which is easily blown away by wind when raining.
HEADSSS
• Home
– Patient and family eats at uncle’s (neighbor’s)
house.
– Patient does not have a good relationship with
mother and step-father
– Mother is sometimes not home, with one account
of disappearing for over 2 months before, leaving
the kids behind
HEADSSS
• Education
– Highest educational attainment: grade 1 at Ilugin
Elementary school
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Lives 1-2 minute walking distance from school
No tuition needed at the school
The mayor gives bags, notebooks and pens, and shoes
Uncles and aunts willing to shoulder the expenses for
uniforms
– Patient expresses the longing to go to school so
that he can get a good job in the future and earn a
decent living
HEADSSS
• Education
– Other siblings are also not going to school while
the year-level of cousins living in the same area
are at par with age
– Mother claims that she wants the children to
study but all of them do not want to do so.
HEADSSS
• Activities
– Hangs out with friends going around Ilugin
– According to neighbors/relatives, the patient
collects garbage as a source of income (the
mother asks money from him)
– Does not wear footwear, even with a foot wound
– Does not read books
HEADSSS
• Drugs and other vices
– According to neighbors/relatives, the patient
smokes cigarettes, but the patient denies this
• Patient admits that many of his friends smoke
cigarettes
– No account of drug usage or alcohol consumption
• The mother is a known alcoholic, who frequently
engages in drinking sessions with her freinds
HEADSSS
• Sex
– No girlfriend, no sexual activities
• Suicide
– Never thought of committing suicide
• Spirituality
– Patient was baptized, but has never gone to Mass
nor has undergone Confirmation
Physical examination
Physical examination
General survey
• Awake
• Alert
• Coherent and answers
questions completely
• Not agitated and not in
apparent distress
Vital signs
• Height: 130 cm (<5th
percentile)
• Weight: 20 kg (<5th
percentile)
• BMI: 11.8 (< 5th percentile)
• Temp: 36.6C
• HR: 80 beats per minute
• RR:32 beats per minute
• Pain scale: 7/10
Physical examination
HEENT
• With lice and nits
• Anicteric sclerae, pink
palpebral conjunctiva
• No TPC, no CLAD
Chest, lungs, heart
• Symmetric chest expansion,
resonant lung fields, with
occasional rhonchi at
bilateral lower lung fields
• PMI at 5th ICS LMCL, normal
rate, regular rhythm, no
murmurs
Physical examination
Abdomen
• Flat, with normoactive
bowel sounds, tympanitic
all 4 quadrants, nontender
and soft
Extremities
• The plantar aspect of the
1st digit of the right foot
was erythematous and
tender, with apparent pus
underneath
• Pulses full and equal
• Patient was limping
Initial clinical assessment
Initial clinical assessment
• Abscess of the plantar aspect of the first digit
of the right foot
• Pneumonitis, resolving
• Undernutrition
Plan
Initial plan
• Paracetamol 250mg/5ml, 6 ml every 4 hours for fever
(10mkdose)
• Co-amoxiclav 250mg/5ml, 6ml every 8 hours for 7 days
– Was given only 2 5ml bottles and was told to purchase the rest
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Active and passive tetanus vaccination
Drainage of abscess if no improvement after 3 days
Advised better diet
Advised to seek assistance for education of patient
Advised to buy or borrow a thermometer
Course of illness
Day 2 of illness
• Home visit
– The night before, the patient developed an
undocumented high-grade fever. He then was
brought to a local faith healer who punctured the
abscess with a non-alcoholized, flame-exposed
needle. Pus was drained. the fever lysed
– During the visit, the patient avoided ASMPH clerk
– Patient still was not wearing any footwear
Day 2 of illness
• Home visit
– Patient was not given the required dose of
medications needed per day (2.5ml co-amox BID)
and was told that the rest was to be purchased
after the visit. Financial constraint.
– Still with no tetanus vaccinations
– Patient was still limping, but to a lesser extent
– Patient was afebrile
– Lesion was less tender
Day 2 of illness
• Home visit
– Noted a nontender, movable, reducible mass a the
left inguinal area that disappeared upon lying
down and appeared after coughing while standing
up (possible indirect inguinal hernia).
• Further probing – was present since birth
– 1-on-1 consult (HEADSSS)
Day 2 of illness
• While talking with CHW’s
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Mother is a drunkard
Patient collects garbage for cash, mom gets the cash
All siblings of the patient also are not going to school
Mom disappeared for 2 months, leaving the kids behind
Mom and dad are separated, mom has live-in partner
• Patient did not go to the OPD
– Changed the medications to cefalexin and gave the full
amount, Ate Carla (CHW) was in charge
Day 6 of illness
• Home visit
– Mother was not there
– Patient was still walking without footwear
– Marked improvement of the toe, patient was
walking straight, but still with pain 2/10.
– Invited the patient, aunt, and neighbor for family
conference in 2 days, with invitation also extended
to mom.
Initial family medicine
assessment
Family Assessment Tools
• Family structure: blended and random family
• Life cycle: family with adolescents
• Family APGAR: Dysfunctional
APGAR
SCREEM
Family conference
People who attended
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Dr. Limuel
3 ASMPH clercks
2 TMC pedia residents
Patient
Aunt
Neighbor
2 cousins
Mother did not attend
Topics discussed
• Reason for conference: the patient and his
well-being
– Problems with the treatment
– School
– Family and home
Problems with treatment
• How come the patient under-dosed?
– Financial
– Human factor (mother and apparent
incompetence)
– Patient’s feelings and fears about doctors
– Apparent uncooperativeness with regards to
drinking the medications
• Seeking outside help for drainage of pus
– Feelings of patient about going to the hospital
Problems with treatment
• Tetanus vaccinations
– Money issues
– Toxoid vaccinations for free at health center
– Passive immunity as a problem financially
School
• Why isn’t the patient in school?
– The givens:
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The school is so near where they live
No tuition
School supplies provided by the mayor
Uniforms to be shouldered by aunts and uncles
– Therefore what is the problem???
• No birth certificate
• Mother does not seem to care
• The kid needs to work to bring in money
Family and home
• Step-father is never home, although maintains
fair relationships with kids
– Just got out of prison
• Mother does not seem to care for the kids
• Mother brings little food to the table
• Everyone continuously tells mother about the
children but the mother doesn’t seem to care
Family and home
• History of mom: eldest, looked after her
siblings since she was young, and practically
raised them
– Insight of aunt: maybe this time she just was
burned out and wanted to live the life she missed
Meeting with Mother
• Objectives
– Create rapport
– Awareness for health of children
– Clarify relationship and presence/absence of the
mother as a caregiver
– Prepare a plan of action for the children’s
schooling
Conclusion
• Extraction of family issues contributing to
current situations
• Illustration of the effects of the mother’s
behavior
• Explored areas of approach
• Demonstrated initiation of action plans
Future plans
• Schedule of tasks to complete with follow-up
by CHWs
• Maintaining good relationship between
children and neighbors
• Future meeting involving grandmother and
mother
• Future meeting involving step-father