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Mid-Course Report December 2009 Family Family type Information & & Assessment Life Cycle Tools stage CUDAL Address: 1016 Eloisa St. Sampaloc Manila Contact No. 735-7539 Mini-Nutritional Assessment Score At risk of malnutrition Mini Mental State Exam Can not be assessed Geriatric Depression Scale Can not be assessed Roles and Functions Communal Breadwinner Dra. Efegenia Family in Later Soliven life (daughter living abroad) Index Patient Dorothea Cudal Female 97 y/o Decision-maker Dra. Efegenia Soliven (daughter living abroad) 1˚ Caregiver Cecilia Cabais (informal caregiver) MCSI Madalas-2 Minsan-5 Halos hindi-4 Diagnosis Dementia Hearing Loss, AU s/p hip replacement (2004) Latest Lab Results and Medications Multivitamins, 1 tab OD Calcium Carbonate, 1 tab BID Plans Medical 1. Continue Multivitamins and Calcium Wellness 1. Dietary advise- eat more vegatebles, fruits, eggs, drink milk and other fruit drinks. 2. Osteoporosis screening 3. Maintain low salt and low fat diet 4. Encourage passive ROM exercises Psychosocial 1. 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 Family type Information & & Assessment Life Cycle Tools stage Roles and Functions MIGUEL Communal Breadwinner Lydia Miguel Address: 1016 Eloisa St.Sampaloc Manila Family in Later years Decision maker Lydia Miguel Contact No. 735-7539 Mini-Nutritional Assessment Score Not at risk Geriatric Depression Scale Not assessedpatient was in Ilocos *Patient owns the house and rents it to boarders. It is her source of income. Index Patient Lydia Miguel Diagnosis Latest Lab Results and Medications Plans SAH Stage II, Atenolol (Therabloc) Medical poorly controlled 50mg, 1 tab OD 1. Continue current medications. Female 60 y/o Multivitamins, 1 tab OD *Patient is currently in Ilocos for renovation of their house. Caregiver said that they talk to Folic Acid, 1 tab OD her often on the phone and claims that she has good BP control. Psychosocial 1. 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 Family type Information & & Assessment Life Cycle Tools stage LANOT Unilaterally extended Roles and Functions Breadwinner Susan Lanot (daughter) Address 1134 Prudencio Family in Later St. Sampaloc years Decision maker Manila Susan Lanot (daughter) Contact No. 09071628213 1˚ Caregiver Florabel Teodoro Mini-Nutritional (neice) Assessment MCSI Score Madalas-1 Not at risk Minsan-1 Halos hindi-9 Mini Mental State Exam Normal Geriatric Depression Scale Normal Index Patient Anicia Lanot Diagnosis DM type 2, uncontrolled Female 76 y/o 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) Latest Lab Results and Medications Plans Metoprolol Medical 50mg/tab, 1 tab BID 1. Continue current medications 2. Daily BP monitoring Amlodipine 3. Glucose monitoring TID 5mg/tab, 1 tab OD 4. Follow-up referral to ENT (hearing loss) and Insulin 26 U am and Ophthalmology (blurring of 14 U pm vision) 5. Screening for gastritis with every family visit 6. 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. Psychosocial 1. Maintain good interpersonal relationship with caregivers and relatives in the household Family Family type Information & & Assessment Life Cycle Tools stage LABRADOR Address 930 Quezon Blvd St. Sampaloc Manila Contact No 0921-7802097 Mini Nutritional Assessment At risk for malnutrtion Geriatric Depression Scale cannot be fully assessed Mini Mental State Exam cannot be fully assessed Unilaterally extended Roles and Functions Breadwinner Virgilio Jacob (son-in-law) Family in Later life Decision maker Angelita Jacob (daughter) 1 Caregiver Angelita Jacob (daughter) MCSI Madalas-1 Minsan-4 Halos hindi-6 Index Patient Diagnosis Luciana Labrador, Alzheimer's disease Female Xerosis 76 y/o Latest Lab Results and Medications Multivitamins, 1 tab OD Plans Medical 1. Continue MVP Wellness 1. Maintain a balance diet 2. Update immunizations: (Pneumococcal, Influenza, Tetanus) 3. Fall precaution 4. For Osteoporosis screening Psychosocial 1. Maintain good interpersonal relationship with her daughter and her family. Family Family type Information & & Assessment Life Cycle Tools stage VICTORIA Address 948 Adelina St. Sampaloc, Manila Contact No 735 1459 Mini Nutritional Assessment At risk for malnutrition Mini Mental State Exam Normal Geriatric Depression Scale Normal Nuclear Roles and Functions Breadwinner Supina Victoria Family in Later (daughter in law) life Decision Maker Supina Victoria (daughter in law) Index Patient Diagnosis Beatriz Victoria SAH stage II, poorly controlled Female Gouty Arthritis 85 y/o Latest Lab Results and Medications Amlodipine 5mg/tab, 1 tab OD Metoprolol 50mg/tab, 1 tab OD Petroleum Jelly, apply TID on affected areas Plans Medical 1. Continue current medications 2. MVP, 1 tab OD 3. For Ophthalmology referral (blurring of vision not fully corrected by glasses) Wellness 1. Maintain balance diet 2. Update immunization *Patient’s (Pneumococcal, tetanus, medications are not Influenza) being taken regularly because of Psychosocial financial 1. Smoking cessation constraints. 2. Improve relationship with her daughter –in-law and her siblings. 3. Proper budgeting Family Family type Information & & Assessment Life Cycle Tools stage RALLOS Nuclear Address 940 Quezon Blvd. Sampaloc Manila Family with adolescents Contact No 704-5083 Mini Nutritional Assessment Not at risk Mini Mental State Exam Normal Geriatric Depression Scale Suggests depression Roles and Functions Breadwinner Romeo Rallos Index Patient Romeo Rallos Male Decision maker Romeo Rallos 1 Caregiver Madeline Rallos (wife) MCSI Madalas-1 Minsan-1 Halos Hindi-9 *Family gets monthly disability pension. 51 y/o Diagnosis Latest Lab Results and Medications DM type 2, Metformin poorly controlled 500mg/tab, 1 tab TID Diabetic foot , left; s/p AKA May 2008 in *Patient’s PGH medications are being taken only BID because of financial constraints. There is no regular CBG monitoring. Plans 1. 2. 3. 4. Medical Continue current medications MVP, 1 tab OD For Ophthalmology referral – baseline evaluation of Dm complications For BUN, serum creatinine, HBA1C Wellness 1. Update immunization (Pneumococcal, tetanus, Influenza) Psychosocial 1. 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 Family type Information & & Assessment Life Cycle Tools stage RAGAZA Address: 932 R. Papa St. Manila Contact No: 733-1297 Mini Nutritional Assessment Malnourished Bilaterally Extended Family in later life Roles and Functions Breadwinner Marilou Ragaza (daughter) Decisionmakers Marilou Ragaza (daughter) Caregiver Marilou Ragaza (daughter) MCSI Madalas:4 Minsan: 4 Halos hindi: 3 Index Patient Diagnosis Flaviana Ragaza Alzheimer’s disease Female Senile cataract, OD Latest Lab Results and Medications MVP 1 tab OD Plans Medical 1. Referral to Neurology 2. Referral to Ophthalmology 3. Referral to dietary for counseling 81 y/o Malnourished Wellness 1. Ensure 2 glasses/day 2. Update immunizations (tetanus, influenza and pneumococcal) 3. Encourage proper hygiene Psychosocial 1. Encourage family support for cataract surgery Family Family type Information & & Assessment Life Cycle Tools stage RAGAZA Address: 932 R. Papa St. Manila Contact No 733-1297 Mini Nutritional Assessment Malnourished Geriatric Depression Scale Normal Bilaterally Extended Family in later life Roles and Functions Breadwinner Marilou Ragaza (daughter) Decisionmakers Marilou Ragaza (daughter) Index Patient Diagnosis Latest Lab Results and Medications Crispin Ragaza SAH stage 1, controlled Amlodipine 10mgtab OD Male Malnourished MVP 1 tab OD 80 y/o Plans Medical 1. Daily BP monitoring at health center 2. Continue current medications 3. Referral to dietary for counseling Wellness 1. Ensure 2 glasses/day and low salt and low fat diet 2. Update Immunizations (tetanus, influenza and pneumococcal) Psychosocial 1. Encourage family support and daily hygiene Family Family type Information & & Assessment Life Cycle Tools stage LAGANZUA Address 1209 A.J. Barlin St Sampaloc, Manila Mini Nutritional Assessment At risk for malnutrition Geriatric Depression Scale Normal Unilaterally extended Roles and Functions Breadwinner Flora Laganzua Index Patient Flora Laganzua Diagnosis Osteoporosis Latest Lab Results and Medications Multivitamins 1 tab OD Fracture R hip Life Cycle Stage Family in later years Decision maker Flora Laganzua Female 81 y/o 1 Caregiver None Senile Cataract OU Dextroscoliosis Underweight Psychosocial problems *Patient currently has no caregiver Mefenamic Acid 500 mg/tab Calcium gluconate 1 tab OD Plans Medical 1. For hypertensive work-up 2. Refer to Orthopedics 3. Refer to Rehab 4. Refer to Ophthalmology 5. Update vaccination (Tetanus, Pneumococcal, Influenza) Wellness 1. Advise balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily 3. Encourage to ambulate with assistance 4. Educate patientson benefit of healthy living and seeking to improve one’s health Psychosocial 1. Encourage good and healthy relationship with borders 2. Encourage borders to spend quality time with the patient Family Family type Information & & Assessment Life Cycle Tools stage GRAVANSOS Extended Address: 1041 Adelina St. Sampaloc Manila Launching Family Mini Mental State Exam Can not be assessed Geriatric Depression Scale Normal Roles and Functions Breadwinner Zaldy, Polly, Myrna Decision maker Zaldy Caregiver Employed by patients daughter Myrna MCSI Madalas :0 Minsan: 9 Halos hindi 1 Index Patient Diagnosis Soledad Gravansos Parkinson’s disease Female Psychosocial problems 79 y/o Latest Lab Results and Medications Biperidine (Akineton) 2mg/tab BID Plans Medical 1. Continue present medications 2. Update vaccination (Influenza, Tetanus, Pneumococcal) 3. Refer to neurology 4. Suggest Multivitamins 1 tab OD Wellness 1. Advice balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily Increase oral fluid intake 3. Encourage to ambulate (w/assistance) 4. Educate patient on benefit of healthy living and seeking to improve one’s health Psychosocial 1. Caregiver-focused social support 2. Encourage good and healthy relationship with family members and peers 3. Encourage each family member to spend quality time with the patient Family Family type Information & & Assessment Life Cycle Tools stage CAABAY Extended Address 1029 Adelina St. Sampaloc Manila Launching Family Contact No 493-7918 Geriatric Depression Scale Normal Roles and Functions Index Patient Breadwinner Marlon Dela Cruz Cristy Caabay Diagnosis Latest Lab Results and Medications SAH St. 2, uncontrolled Losartan 100mg/tab OD t/c Senile Cataract Amlodipine 5mg/tab OD Female Decision maker Marlon Dela Cruz 66 y/o Psychosocial problems Plans Medical 1. Continue with present medications 2. Daily BP monitoring and recording 3. For: CBC with platelet, Urinalysis, Lipid Profile, 12LECG, Chest X-ray, FBS 4. Update vaccination (Pneumococcal, Influenza, Tetanus) 5. For referral to Ophthalmology Wellness 1. Advice balanced diet, with low fat, low salt, high fiber diet 2. Encourage to drink 8-10 glasses of water daily 3. Encourage to ambulate w tih assistance 4. Continue vitamins supplementation 5. Educate patients on benefit of healthy living and seeking to improve one’s health Psychosocial 1. Encourage good and healthy relationship with family members and peers Family Family type Information & & Assessment Life Cycle Tools stage RICARDO Address: 1829B Sisa St, Sampaloc, Manila Contact No. 09272442408 Mini Nutritional Assessment Not at risk for malnutrtion (previous diagnosis) Mini Mental State Exam Can not be assessed Geriatric Depression Scale Can not be assessed Roles and Functions Index Patient Diagnosis Latest Lab Results and Medications Unilaterally extended Breadwinner Vivian (patient) Vivian Ricardo SAH St 2, uncontrolled Metoprolol 50mg BID Launching Family Decision maker Vivian (patient) Female ASHD, CAD, LVH ISMN 30mg OD t/c Musculoskeletal strain ASA 80mg OD 55 y/o t/c Gastritis 2 to chronic ASA use Simvastatin 20mg ODHS Losartan 50mg + Hydrochlorothiazid e 12.5mg OD Omeprazole 20mg OD Plans Medical: 1.Daily BP monitoring 2.For 12L ECG, lipid profile, FBS 3.For ophthalmologic examination Wellness: 1.Recommend light snacks every 2 hours for waking hours 2. Recommend DASH diet 3.Strict compliance with medications 3. 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 Family type Information & & Assessment Life Cycle Tools stage RICARDO Address 1722 Ibarra St, Sampaloc, Manila Contact No 09194236146 Mini Nutritional Assessment Not at risk (score 12) Mini Mental State Exam Mild Impairment (score 23) Geriatric Depression Scale Normal (score 5) Bilaterally extended Family in later years Roles and Functions Breadwinner Rosario Castillo (Daughter) Decision maker Rosario Castillo (Daughter) Index Patient Diagnosis Latest Lab Results and Medications Concepcion Ricardo SAH St 2, controlled Female t/c Senile cataract OD ASA 80mg OD s/p cataract surgery OS Petroleum jelly OD and prn Allergic Contact Dermatitis 2 to Rubber Sandals, both feet 81 y/o Amlodipine10mg + Valsartan 160mg OD Plans Medical: 1.Daily BP monitoring and recording 2.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 hours 2. Recommend DASH diet 3.Strict compliance with medications 4. Increase ADL 5. Encourage daily reading of newspapers Psychosocial: 1.Encourage more ocial involvement with neighbors Family Family type Information & & Assessment Life Cycle Tools stage ROFO Bilaterally Extended Roles and Functions Breadwinner Edna Garcia (daughter) Address: 1726B Ibarra St, Family in Later Sampaloc, Life Decision maker Manila Edna Garcia (daughter) Contact No. 7116657 Mini Nutritional Assessment Not at risk (score 14) Mini Mental State Exam Mild impairment (score 27) Geriatric Depression Scale Normal (score 3) Index Patient Lydia Rofo Diagnosis Latest Lab Results and Medications SAH St 1, controlled Amlodipine 5mg BID Gouty arthritis Verapamil 80mg OD Female 79 y/o ASIS fracture, left, s/p skeletal traction Plans Medical: 1. Daily BP monitoring and recording 2. For ophthalmologic examination Wellness: 1. Compliance with medications 2. Recommend DASH diet and avoidance of organ meats, sardines, mussels 3. At least 8 glasses of water a day 4. Reading newspaper daily 5. Increase activities of daily living Psychosocial: 2.Encourage involvement with neighbors Family Family type Information & & Assessment Life Cycle Tools stage SANCHEZ Address: 1855 Sulu St., Sampaloc, Manila Mini Nutritional Assessment At risk for malnutrition (score 21) Geriatric Depression Scale Normal (score 5) Mini Mental State Exam No impairment (score 27) Bilaterally Extended Launching Family Roles and Functions Index Patient Breadwinner Filemon Sanchez, Jr. (Son) Filemon Sanchez Decision maker Filemon Sanchez, Jr. (Son) 70 y/o Male Diagnosis Latest Lab Results and Medications DM type 2, Amlodipine 5mg controlled, s/p OD BKA , right (2008) Metformin 500mg OD SAH St. 1, controlled Tinea versicolor, upper back Venous Insufficiency, Left foot Tobacco addiction r/o Lung CA Plans Medical: 1. Daily BP and CBG monitoring and recording and daily foot examination 2. Referral to DM center for glucometer calibration 3. For yearly ophthalmologic and serum creatinine examination and HbA1c and FLP every 3-6 months 4. Suggest shift to ACE inhibitor 5. Ketoconazole 2% shampoo as a body wash 6. For Duplex ultrasound of lower extremities and pelvis 7. For chest x-ray (PA, L views) 8 Smoking cessation counselling 9. Referral to Rehabilitation Medicine 10. Update immunizations (influenza, pneumococcus, tetanus) Wellness: 1. Recommend DASH diet 2. For daily home exercises once with prescription from Rehabilitation Medicine 3. Strict compliance with medications 4. Reading newspaper daily 5. Wear loose fitting clothing and avoid sweating Psychosocial: 1. Encourage involvement with friends who don’t smoke Family Family type Information & & Assessment Life Cycle Tools stage SOLIONGCO Unilaterally extended Address: 1114 Carola st. Family in later Sampaloc, life Manila Mini-Nutritional Assessment Not at risk for malnutrition (score 12) Geriatric Depression Scale Normal (score 2) Mini Mental State Exam No impairment (score 28) Roles and Functions Breadwinner Juliet Soliongco (daughter-in-law) Decision Maker Juliet Soliongco (daughter-in-law) Index Patient Diagnosis Aurora Soliongco SAH St.II controlled Female Senile cataract, OU 95 y/o Bronchial Asthma, not in acute exacerbation Latest Lab Results and Medications Telmisartan HCl (Pritor Plus) 500mg/tab ODHS Plans Medical: 1. Daily BP monitoring and recording 2. Referral to Ophthalmology for baseline eye exam and evaluation of cataracts 3. Update immunizations (influenza, pneumococcus, tetanus) Wellness: 1.Recommend DASH diet 2.Strict compliance with medications 3. Education on avoidance of airborne allergens, air pollutants and irritants 4. Daily reading of newspaper as able Psychosocial: 1.Encourage her current involvement in social barangay groups 2. Encourage current level of ADLs performed because it enhances her feeling of self worth Family Information & Assessment Tools DELA CRUZ Address: 1035 Miguelin St. Sampaloc, Manila Mini-Nutritional Assessment Not at risk for malnutrition (score:12) Geriatric Depression Scale: Normal (score:2) Mini Mental State Exam: Mild impairment (score: 23) Family type & Life Cycle stage Unilaterally Extended Family in later years Roles and Functions Breadwinner Eugenia Dela Cruz (sister-inlaw) Index Patient Diagnosis Librada Dela Cruz HPN st.II controlled Female ASHD, CAD NIF, Chronic Stable Angina Class IIB Decision maker 79y/o Eugenia Dela Cruz (sister-inlaw) Osteoarthritis Latest Lab Results and Medications Plans Metoprolol 100mg/tab 1 tab ODHS Medical: 1. Daily BP monitoring and recording 2. Screening for gastritis during Trimetazidine family visits 35mg/tab 1 tab BID 3. Update immunization (influenza, pneumococcal, Imidapril 5mg/tab 1 tetanus) tab OD 4. For yearly ophthalmologic examination ISDN 5mg/tab 1 tab prn for chest pain Wellness: 1.Continue strict compliance with Clopidogrel medications 75mg/tab 1 tab 2. Recommend DASH diet ODHS 3. Encourage to drink 8-10 glasses of water daily Digoxin (Lenoxin) 3. Educate patient and relatives 250mg/tab 1tab OD on the signs of drug toxicity 4. Encourage daily reading of Celecoxib papers 200mg/tab 1 tab 5. Encourage ADL as tolerated prn for pain only Omeprazole 20mg/tab 1tab OD Psychosocial 1.Sharing of responsibilities in taking care of patient 2.Encourage good and healthy relationship with family members and peers Family Information & Assessment Tools Family type & Life Cycle stage QUEROL Nuclear Family Address: 1089 Don Quijote St. Sampaloc Manila Family in later years 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 Roles and Functions Breadwinner Salud Querol Index Patient Remedios Querol Decision maker Female Salud Querol 85 y/o Caregiver Salud Querol Diagnosis Latest Lab Results and Medications SAH St.II, uncontrolled Amlodipine 10 mg/tab 1 tab OD DM type II, controlled Allopurinol 300mg/tab 1 tab OD Gouty Arthritis Malnourished Amiodarone 200mg/tab 1 tab OD Clopidogrel 75mg/tab 1 tab OD Plans Medical 1. Daily BP and blood glucose monitoring and recording 2. Suggest serum creatinine 3. Screening for gastritis during family visits 4. Follow-up with physician 5. Update immunizations (influenza, pneumococcus, tetanus) Wellness 1. Compliance with medications 2. Recommend DASH diet and diet low in organ meats, sardines, processed foods 3. Recommend Ensure two glasses daily and drinking 810 glasses of water daily 5. 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