Transcript family history

Family Case Presentation
Baslar, Isa
Belmonte, Celeste
Brillante, Christie
Bulatao, Jose
Cheng, Monina
GENERAL OBJECTIVE
To re-evaluate a patient currently
enrolled in the UST-DFM Family
Health Care Program for continuance
of care
SPECIFIC OBJECTIVES
 To identify medical, psychological, social and
economic problems of the index patient and her
family
 To analyze the family dynamics using the family
assessment tools
 To assess the stage of the family in the Illness
trajectory and aid them until they reach the final
stage
 To formulate a family health care plan
 To give recommendations as to the continuation of
care under the Family Health Care Program
GENERAL DATA
 F. L.
 81 years old
 female
 Roman Catholic
 Filipino
 Single
 Store owner
 DOB:4/23/28
HISTORY OF PRESENT ILLNESS
Jan 19, 2009
Jan 22, 2009
Jan 29, 2009
CONSULT
• Patient was walking outside the UST church when her umbrella (she uses as a cane)
slippped and she fell. Patient was able to stand and walk after the incident.
• Patient claims to have slight pain and LOM, no edema. No consult done, no
medications taken
• Due to persistence of symptoms, patient called for a “hilot”. There was increase in the
severity of pain after the massage.
• edema was noted as well.
• Patient consulted a physician due to increase in severity of pain. An Xray was done and
revealed hip fracture
• Patient was advised surgery but she refused
REVIEW OF SYSTEMS
 (-) sweats, (-) insomia, (-)anxiety, (-)interpersonal relationship difficulties
 (-) color changes, (-) rash, (-) photosensitivity, (-) changes in hair/ nails/skin,
 (-) itchiness
 (+) blurring of vision, (-)tinnitus, (-)discharge, (-)epistaxis, (-)discharge ,
 (-)bleeding gums, (-) throat soreness
 (-) hemoptysis, (-)chest pain, (-)cough
 (-)nausea, (-)vomiting, (-) hematemesis, (-) melena, (-) hematochezia,
 (-) dysphagia,(-)epigastric pain,(-)heartburn
 (-) heat/cold intolerance, (-)polyphagia, (-)polydipsia (-) polyuria
 (-) muscle pain, (-) joint pain,
 (-) varicosities, (-)claudication
 (-) dysuria, (-)flank pain, (-)frequency,(-)hesitancy,(-)urgency
 (-)headache, (-) seizures
 (-) easy bruisability
PERSONAL & SOCIAL HISTORY
 Non-smoker
 Non-alcoholic beverage drinker
 Denies illicit drug use
 Diet: Mixed diet (vegetables, fruits, meat)
 Store owner, retired teacher
 BS Education graduate
 Does household chores, goes to churches and market
PAST MEDICAL HISTORY
 Malaria in 1938 (10 yrs old)-treated by a family
physician
 (?) Hypertensive since 2005, with BP elevations of
SBP 130-140/ DBP 80-90.
 No DM, No Asthma, no PTB
 No operations
 (+) allergy to medicol
 Immunization: Unrecalled
FAMILY HISTORY
 (-) asthma
 (-) allergy
 (-)PTB
 (+)Kidney disease – sister
 (+) HPN – sister
 (-) DM
 (-) Cancer
PHYSICAL EXAMINATION
 GENERAL SURVEY: conscious, coherent, oriented
to 3 spheres, ambulates with assisstance, not in
cardiorespiratory distress
 BP 130/80 mmHg PR 92/min RR 20/min Temp 36.7C
 SKIN: warm, moist, no active dermatoses
 HEENT: pink palpebral conjunctivae, anicteric sclerae,
(+) cataract,OU, no nasoaural discharge, moist buccal
mucosa, non-hyperemic posterior pharyngeal wall,
tonsils not enlarged
 NECK: no palpable cervical lymph nodes, supple neck,
thyroid not enlarged, no other palpable masses
PHYSICAL EXAMINATION
 CHEST: symmetrical chest expansion, no retraction,
clear breath sounds
 HEART: adynamic precordium, regular rhythm, apex
beat at 5th LICS MCL, no mumurs
 ABDOMEN: flat, normoactive bowel sounds, soft, nontender, no masses palpated
 (+) gibbus at level of T6-T7, (+) dextroscoliosis
 EXTREMITIES: no cyanosis, no edema, pulses full and
equal
 ROM: (+) limitation in bilateral hip flexion, bilateral
shoulder abduction and extension
NEUROLOGIC EXAMINATION:
 Mental Status: Conscious, coherent, oriented to three
spheres
 Cranial nerves: pupils 2-3 mm ERTL, EOMs full and equal,
V1V2V3 intact, can raise eyebrows, can close eyes against
resistance, no facial symmetry, can shrug shoulder against
resistance, can swallow, tongue midline on protrusion
 Motor: no tremors, no muscle fasciculations, MMT: 5/5 on
all extremities
 Cerebellar: Can do APST, finger-to-nose test; no gait
abnormalities
 DTR’s: ++ on all extremities
 Sensory: No sensory deficit
 No Babinski reflex
 No nuchal rigidity, Brudzinski sign, Kernig’s sign
GERIATRIC ASSESSMENT:
 Mini Mental State Examination: 30 (normal)
 Katz Activities of Daily Living Scale- With
assistance in bathing, dressing, toileting, &
transfer; with occasional incontinence; feeds
without assistance
 Geriatric Depression Scale: 3 (normal)
ASSESSMENT OF INDEX PATIENT
Osteoporosis
Fracture, R hip
Senile Cataract, OU
Dextroscoliosis
FAMILY ASSESSMENT
P. NOVAL
ADELINA ST
X
ELOISA ST
DAPITAN
BARLIN ST
UST
STAIRS
CR
PATIENT’S
ROOM
CHAIR
TABLE
WINDOWS
TV
CHAIR
E.FAN
CABINET
PATIENT’S BED
ENVIRONMENTAL HISTORY
 Concrete type, 2-storey building
 House-rented
 patient rents 8 bedrooms (patient occupies only one room
and rents the others)
 Fairly Clean , well-ventilated and well-lit
 Electricity from Meralco
 Water source from NAWASA but drinking water - purified
water
 Toilet Type- flush, Drainage is good
 Regular waste disposal, no segregation but regularly
collected
 Do not have pets but there are many stray animals and pests
in the neighborhood
 Area is accessible by- taxi, jeep, tricycle
FAMILY TREE
Laganzua Family
1209 A.J. Barlin St
Sampaloc, Manila
December 3, 2009
Rufo , 72
Inocencia,100
Jose,30
Lorenza,81 Adelaida, 27 Andrea,22 Jesus,60 Asuncion, 60
Henry
Clarissa
Vivian
Carmelita,62 Esteban,65
Odelon
Serrina
MeAnne,33 Ariel,31
Flora, 81
Michael,35 Arlene,32
Seth, 6
Vaughn Matthew,2
Anthony
Mae
Family Structure
 Type of Family- Unilaterally extended
 Ordinal Position: Third
 Social Class Pattern : Low Income Family
 Family Set-Up: Democratic
FAMILY
PROFILE
AGE/ RELATION EDUCATIONAL
SEX
TO HEAD ATTAINMENT
OCCUPATION
CURRENT
HEALTH
STATUS
Flora
81/F
Aunt
B.S. Education
graduate
Retired teacher,
store owner
Osteoporosis
Fracture, R hip
Senile Cataract,
OU
Dextroscoliosis
Me-Anne
33/F
Wife
2nd year- B.S.
Computer Science
Housewife
Arachnoid cyst(?),
s/p spine surgery
(June 2009)
Ariel
31/M
Head
B.S. Nursing
Nurse in San
Lazaro
Essentially
Normal
Seth
6/M
Son
Prep
student
Asthma
FAMILY LIFELINE
 2002- Ariel and MeAnne were married and
rented a room beside Flora’s
 2003- Seth was born
 2007- Seth started Nursery school
 2009 (Jan) Flora had a fall which caused hip fracture
 (June) MeAnne was diagnosed with a spine cyst
and was operated
ECONOMIC PROFILE
Income
22,ooo
Expenses
 FOOD
 EDUCATION
 MEDICATION
PhP
10,000
3,000
1,000
 MISCELLANEOUS
 (electricity, water, house rent) 4,000__
TOTAL EXPENSES:
Savings:
18,000
4,000
Flora Laganzua
Me-anne
Laganzua
1. Ako’y nasisiyahan dahil nakakaasa ako ng
tulong sa aking pamilya sa oras ng problema.
2
2
2. Ako’y nasisiyahan sa paraan ng pakikipag-usap
sa akin ang aking pamilya tungkol sa aking
problema.
2
1
3. Ako’y nasisiyahan at ang aking pamilya ay
tinatanggap at sinusuportahan ang aking mga
nais na gawin patungo sa mga bagong landas para
sa aking ikauunlad
2
2
4. Ako’y nasisiyahan sa paraang ipinadadama ng
aking pamilya ang kanilang pagmamahal at
nauunawaan ang aking damdamin katulad ng
galit, lungkot at pagibig.
2
1
5. Ako’y nasisiyahan na ang aking pamilya at ako
ay nagkakaroon ng panahon sa isa’t-isa.
1
2
TOTAL (Interpretation: 8-10 highly functional,
9
8
FAMILY APGAR
4-7 moderately dysfunctional, <4 severely dysfunctional)
SCALE: 2-Palagi, 1-Paminsan-minsan, 0-Halos hindi
HIGHLY FUNCTIONAL
PARAMETER STRENGTH
WEAKNESS
SOCIAL
[ / ] Open intrafamilial lines of
communication
[ / ] Absence of animosity/rivalry
[ / ] Healthy/supportive
intrafamilial relationships
[ / ] Healthy/supportive
extrafamilial relationships
CULTURAL
[ / ] Absence of or very few
beliefs/practices that are
unacceptable to our culture or
negatively affect way of living (e.g.
institutionalization of elderly,
dependency of married children to
parents, value for education, does
not advocate family closeness,
seeking help from traditional
healers, etc.)
RELIGIOUS
[ / ] Spirituality is positively
influencing way of life
[ / ] Practicing one’s faith,
enduring because of his faith
PARAMETER
STRENGTH
WEAKNESS
EDUCATIONAL [ / ] Level of education is not a
hindrance to achievement,
livelihood, success
[ / ] Level of education
facilitates comprehension of
most challenging circumstances
ECONOMIC
[ / ] Ability to allocate funds
appropriately
[ / ] Ability to make ends meet
most of the time
MEDICAL
[ / ] Good compliance with
medical management
[ / ] Aware and practices
wellness and environmental
sanitation.
[ /] Inappropriate medical consultation
MODIFIED CAREGIVER STRAIN
INDEX
 Me-anne Laganzua
• Madalas- 2
• Minsan – 1
• Halos Hindi – 8
• Dra. V asked for the interpretation of score… (help na lang
sa pagresearch how to interpret this…
FAMILY LIFE CYCLE STAGE
Family with young childrenstarts with pregnancy for the 1st
child to emergence of
adolescents.
FIRST ORDER CHANGE
1.
Supplying adequate space , facilities and equipment for the
expanding family
2.
Meeting predictable and unexpected costs of family life
with small children
3.
Sharing responsibilities within the extended family and
between members of the growing family
4.
Maintaining mutually satisfactory sexual relationship and
planning for the future children
5.
Creating and maintaining effective communication system
in the family
6.
Cultivating the full potentials of relationship with relatives
within the extended family
7.
Tapping resources, serving needs, and enjoying contracts
outside the family
8.
Facing dilemmas and reworking philosophies
 .
 .
 .
 .
 .
SECOND ORDER CHANGE
1. Accepting marital system to make
space for children
2. Taking on parenting role
3. Re-alignment of relationship with
extended family to include parenting
and grandparenting roles
 .
 .

.
FAMILY ASSESSMENT
Family with young children –
UNILATERALLY EXTENDED
STAGE IN THE ILLNESS TRAJECTORY
STAGE V:
Adjustment to the permanency
of the outcome.
Adjustment to the permanency of the
outcome
 the family realizes that they must accept & adjust
to a permanent disability
 pattern believed to be temporary must be accepted
as permanent outcome
FAMILY HEALTH CARE PLAN: Index Patient
TYPE OF CARE
WELLNESS
{promotive,
preventive}
MEDICAL
PSYCHOSOCIAL
PROBLEM
Patient maintains a balance
diet
Last
immunization:
unrecalled
Osteoporosis with Fracture ,
R hip
Senile Cataract, OU
With episodes of BP
elevations
Patient is unable to go out of
the house because of her
condition. She said that she
goes to different churches
everyday
before
the
accident. It is also one of
the reasons why she could
not follow-up at the OPD
clinic.
RECOMMENDATIONS
For immunization: Tetanus,
Pneumococcal, Influenza
Encourage ROM exercises daily
For Rehabilitation therapy
For orthopaedic consult
For Ophthalmologic consult
For Hypertensive work-up
Encourage the other family
members to talk to her more
often.
A wheelchair would be
beneficial to be able to go out
and meet other people.
FAMILY HEALTH CARE PLAN: Other family
members
TYPE OF CARE
WELLNESS
{promotive,
preventive}
FAMILY
PROBLEM
MEMBER
Me-Anne
Ariel
Seth
MEDICAL
Me-Anne
Seth
PSYCHOSOCIAL
Me-Anne
RECOMMENDATIONS
Maintain balance diet
Update immunization
Daily exercise
s/p spine surgery for For ff-up with Neurology
arachnoid cyst(?) June
2009
Asthmalast
attack Avoid triggers
unrecalled
Stopped working after
the
operation
and
decided
to
be
a
housewife
She could join organization
and do activities other than
household
chores
and
caring for her aunt.
THANK YOU!!!