Transcript bj`s last testimony

BJ’S LAST
TESTIMONY
Family Medicine Case Presentation
15 January 2010
Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong
Case Background
General Data




23-year-old
Male
Iglesia ni Cristo
Lives in Manila
Chief Complaint

Cough
History of Present Illness

cough

3 weeks PTA


unproductive
No associated symptoms (fever, colds,
nausea and vomiting, change in bowel
movement, dysuria)
No medications taken, no consults done
Cough persisted


Persistence of cough
Now associated with chest pain




Heaviness especially when coughing
3/10 pain scale
No other associated symptoms
No medications taken, no consults
done
1 week PTA
History of Present Illness
Symptoms persisted


1 day PTA
Unproductive cough
Fever



Chest pain 8/10




Consult
Intermittent, at Tmax: 38oC
Took paracetamol 500mg once: partial relief
More when coughing
Relieved when sitting down
No palpitations, syncope,
Difficulty of Breathing
Persistence of
symptoms
Review of Systems
General: no weight loss, no change in appetite
Cutaneous: no lesions, no pigmentation, no pruritus
HEENT: occasional headaches, no redness, no
aural/nasal discharge, no neck masses, no sore
throat
Cardiovascular: no easy fatigability, fainting spells,
palpitation
Review of Systems
Gastrointestinal: no nausea and vomiting, no loose
bowel movements, no constipation
Genitourinary: no genital discharge, no pruritus, no
problems in urination
Endocrine: no polyuria, polydypsia, no heat/cold
intolerance
Hematopoietic: no easy bruisability, or bleeding
Past Medical History
No Hypertension, Diabetes, Asthma, PTB
No Cancer, Allergies, Trauma
No previous surgeries
No previous hospitalizations
Not taking any maintenance medications
Family History


History of diabetes
No hypertension, heart disease, cancer, stroke,
kidney disease, asthma, or allergies
Personal and Social History



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


Customer service representative, night shift
Lives alone in own apartment
Multiple unprotected sexual male and female
partners
College graduate
Non-smoker
Occasional alcoholic beverage drinker
No substance abuse
Course in the Wards

Initially diagnosed with CAP
 Started

on cefuroxime and ampicillin
Patient unresponsive, started to have desaturations
 Sputum
sample turned out to be positive for
mycobacterium, and started treatment
 Shifted to levofloxacin and carbapenem

Still having desaturations and DOB, moved to ICU
Course in the Wards

In the ICU
 Connected
to a mechanical ventilator and CPAP
 Still unresponsive to treatment
 Now suspected to have PCP
 Scheduled to have a tracheostomy
 Slowly
weaned off CPAP
 Patient continuously had desaturations, then GCS 3
 Family
signed for DNR
 Patient expired
Family System
Family System
Legend:
Immunocompromised
Diabetes
?
Family System

Patient
 Single,
Young adult, Lives alone
 Several partners

Parents
 Father
works as the church minister,
 Mother is the children’s primary caregiver

Family
 Eldest
brother, 2 younger sisters
Impact of Illness
Family Life Cycle

Launching
 Goal:
Being one’s own person
 Secondary task
 Differentiation
of self from family of origin
 Development of peer relationships
APGAR
Almost
always
1.
1.
1.
1.
1.
I am satisfied that I can turn to my family
for help when something is troubling me.
I am satisfied that my family talks things over
with me and shares problems with me.
I am satisfied that my family accepts and
supports my wishes to take on new activities
or directions.
I am satisfied that my family expresses
affection and responds to my emotions,
such as anger, sorrow and love.

I am satisfied with the way my family and I
share time together.
Total Score 6/10
Some of
the time

Hardly
ever



Modified from Smilkstein G: The family APGAR: A proposal for family function test and its use
by physicians, J . Family Practice 6(6), 1978. Reprinted by permission of Appleton and Lange, Inc
Stakeholder Analysis
Stakeholder
Interest in Issue
Role
Level of
Influence
BJ
Getting well, Controlling my illness,
Confidentiality
Ally
High
Mother
Getting my son well, safe and
home; Keeping the family together
Ally
High
Father
Getting my son well, safe and
home
Ally
Medium
Siblings
For my brother to get well and go
home soon
Ally
Low
Grandmother
Caregiver when the mother needs
to rest; For my grandson to get
well and go home soon
Resistor
Low
Other Family Issues

Other family issues
 Religion
 Iglesia
ni Kristo
 Father is a minister
 Patient’s
 Only
decision and confidentiality
the mother knew
 Communication
 Pneumonia
to other family members
not responding to antibiotics
 Why the need to confine in an ICU
SCREEM
Addressing Disease within a Family Framework
Social-Cultural-Religion-EconomicEducation-Medical Tool
Resources
Social
Cultural
Religion
Economic
Education
Medical
Network in the workplace
Harmonious relationship with
colleagues
Respect for parents
There are no religious differences in
dealing with the sick among Iglesia Ni
Cristo
Personal income
Empowerment to make own financial
decisions
Family members are open to
financially assisting
Patient is a college graduate who is
able to comprehend the medical needs
required for his illness
Health card holder and immediate
access to health needs, improving
health seeking behavior
Pathology
Lack of communication with family
Stigma for possible venereal disease
Conservative group who would
disapprove of the illness
Expensive medical care requirements
No known savings yet
Non-coverage for illness related to risky
lifestyle behaviors
In a tertiary hospital with high price for
health care without his HMO coverage
MEDICAL ISSUES
ICU: Family Meetings

“Screened” family meetings
 Patient’s
wishes of confidentiality
 Treatment and current status of
patient
 Focused on issues regarding
management of pneumonia
 Family
members and roles
 Mother:
confided with father
 Father: decision maker
 Sisters: support group
 Grandmother: active spokesperson
HIV Management

Medical and Psychological
 address
symptoms
 address depression

Social and Legal
 Contact

tracing and screening
Confidentiality
 Difficulty
obtaining consent for
HIV testing
 CD4 count as alternative
 Delayed aggressive treatment
Psychosocial Issues
Psychosocial Issues
 STIGMA
 Societal
stigma
 Homosexuality: acceptable to society?
 Religious stigma
 Having the infection as a sign of moral fault
Psychosocial Issues

Financial burden
 Issue
with HMO coverage for lifestyle-related diseases
Psychosocial Issues

Communication barrier
 Psychosocial
profile of
family
 Cultural issues on HIV and
homosexuality
 DNR
and INC doctrines
about life
 No
clear practice on
remembering those who died
 No doctrine on the issue of
DNR
Psychosocial Issues
 Bereavement
 No
and Acceptance of loss
clear understanding of how this came about
 Difficult to communicate to family members the reason for
BJ’s confinement
 The issue of communicating his testimony to their community
Family Wellness Plan
Family Wellness Plan

Identify family support roles
 Father
as source of strength
 Iglesia ni Cristo community


Delve deeper on grief and
bereavement
Family counseling regarding
their own feelings towards the
loss
Family Wellness Plan

End goal regardless of
religion would be the
overall acceptance of
the situation and the
ability to reach a new
equilibrium beyond the
death of their loved
one.
Learnings as a Physician
Learnings as a physician


More than diagnosis and
management
RAPPORT
 Trust
between physician
and patient is the key to
open up the process of
revealing important
information
Learnings as a physician
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
PHYSICIAN = ADVOCATE
Equipped with the Right Tools,
Right frame of mind
Responsibility of a physicianadvocate
 Ensure
that patient is well
informed
 Prevent stigma in healthcare
setting
 Holistic approach – family is
the key
Every physician should be an advocate for
each patient.
Equipped with the right tools and the right
frame of mind, we begin to realize that
illness can be utilized to serve the good of
the patient and the family.
Illness is associated with grief and loss of
hope, but if we open up our minds and
look closer, we will see that Illness also
paves the way to unity and healing- for
the patient, family, and physician.
BJ’S LAST
TESTIMONY
Family Medicine Case Presentation
15 January 2010
Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong