Transcript Family Medicine Case Presentation

Abad, Imperial, Javate, Palma, R. Uy, Valencia
ASMPH 2012
Objectives
 To discuss the family profile of Pradel family
 To establish the family diagnosis using family assessment tools
 To present a case of trauma secondary to a vehicular accident
 To discuss the impact of vehicular trauma to a family
 To briefly discuss the road safety and legal issues pertinent to
the case
Index Case Profile
 MP
 17 years old
 Female
 Occidental Mindoro
Chief Complaint
 Abdominal pain
Vehicular Accident
 NOI: Vehicular Crash (Motorcycle vs Tricycle;
Motorcycle vs Truck)
 TOI: 2:30pm
 DOI: December 8, 2010
 POI: San Jose, Occidental Mindoro
Primary Survey
 Airway: Patent
 Breathing:
 RR = 26bpm
 Symmetric chest expansion and clear breath sounds
 (-) dyspnea
 Circulation:
 HR = 94bpm
 (-) neck veins (-) murmurs
 Disability:
 (-) sensory or motor deficits
 GCS:15 E4,V5,M6 although irritable and uncooperative
 Pupils 2-3mm EBRTL
 Exposure: Contusions, both eyes. Abrasion, chin. Hematoma, lateral
forearms
Secondary Survey
 Signs and Symptoms
 Abdominal pain (3 days PTA, after VC): diffuse, cramping
and sharp pain; 8 – 10 / 10; Aggravated by palpation
 Allergies: none
 Medications: none
 Pertinent Past Medical History:
 (-) previous hospitalizations / surgeries
 Last Oral Intake: more than one day
 Events leading to the incident
Events leading to the incident
 3 days PTC
 Returning a motorcycle she borrowed
 Wearing a helmet
 Going fast, attempted to overtake
 Last motorcycle to overtake, sideswept
 Off-balance, veered to opposite lane
 Crashed head-on to a decelerated truck
 Said to have been unconscious
 No witnesses available on interview
 Reliability of father = 75%
Events after the incident
 Brought to a nearby hospital in Mindoro
 Admitted, but family opted to transfer to a better facility
 2 days PTC
 Admitted at Batangas General Hospital
 Cranial CT was said to be unremarkable
 Subcapsular hematoma, liver
 Lipase: 2000+
 Advised ICU stay, but patient was uncooperative
Events after the incident
 1 day PTC
 Transferred to Paranaque Doctors Hospital
 Family opted transfer to EAMC
 Transfer to SMPCH
 Past Medical History:
 Sepsis (11 days old)
 Family history:
 Asthma – mother
 DM - grandmother
 Social history:
 College student
 Claims (-) smoking, drinking, drugs
 Active in church (Born Again)
Physical Examination
 Conscious, irritable, not in cardiorespiratory distress
 BP: 110 / 70 mmHg
 Temp: 36°
 HR: 94
 RR: 26
Physical Examination
 Skin
 brown skin color, good turgor, no rashes, multiple abrasions
 HEENT
 (+) periorbital hematoma, bilateral with edema, anicteric sclerae,
pink palpebral conjunctiva, no TPC, no CLAD
 Pulmonary
 Symmetric chest expansion, clear breath sounds, no rales, no
wheezes, (+) tachypneic
 Cardiovascular
 Adynamic precordium, apex beat at 5th ICS LMCL, NRRR,
distinct S1 S2, no murmurs
Physical Examination
 Abdomen
 Flat abdomen, hypoactive BS, no masses, no organomegaly
(+) direct tenderness all quadrants, (+) involuntary guarding
 Genitourinary
 No CVA tenderness
 Extremities
 (+) Hematoma, forearm bilateral, no cyanosis, no edema, full
and equal pulses
Clinical Impression
 Multiple injuries secondary to vehicular crash
 Acute surgical abdomen secondary to blunt abdominal
trauma secondary to vehicular crash
Medical and Surgical Managment
 Admitted; IVF, NGT, Foley Catheter
 Emergency Explore Laparotomy
 Evacuation of hemoperitoneum
 Ligation of bleeders
 Reactive Appendicitis

Appendectomy
 Pancreatitis secondary to trauma
 ICU
 Cefuroxime / Metronidazole / Imipenem
 Omeprazole / Ketorolac / Vitamin K
Family Profile
Name of Family
Member
MP
Relation to Patient
Age/Sex
Occupation
Patient
17 / F
GP
JP
JP
KP
Mother
Father
Younger brother
Youngest brother
39 / F
47 / M
15 / M
12 / M
College
Sophomore
Housewife
Baker
High school senior
High school
freshman
Family Genogram
PRADEL FAMILY
Diabetes Mellitus
Multiple injuries
secondary to
vehicular crash
5
7
Family Life Cycle
 Family with adolescents
Family Map
APGAR
ADAPTATION
Ako’y nasisiyahan dahil sa nakakaasa ako ng tulong sa
aking pamilya.
PARTNERSHIP Ako’y nasisiyahan sa paraaang nakikipagtalakayan sa
akin ang aking pamilya tungkol sa aking problema.
GROWTH
Ako’y nasisiyahan at ang aking pamilya ay tinatanggap
at sinusuportahan ang aking mga nais gawin patungo
sa mga bagong landas para sa aking ikauunlad.
AFFECTION Ako’y nasisiyahan sa paraang ipinadadama ng aking
pamilya ang kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit, lungkot at pagibig.
RESOLVE
Ako’y nasisiyahan na ang aking pamilya at ako ay
nagkakaroon ng panahon sa isa’t isa.
OVERALL ASSESSMENT
MP
patient
GP
mother
JP
father
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
10
10
9
SCREEM
PARAMETER
Social
RESOURCE
Good relationship between family members, neighbors and fellow
church members
PATHOLOGY
None
Social activities of family are mainly church-related
Family is very proud to be a Filipino with no intention to leave the
country.
Cultural
None
Family encourages children to participate in social welfare and church
related activities
Family is a religious Born-again Christian who devoutly respects the
traditions of their church.
Religious
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 moment
None
SCREEM
PARAMETER
RESOURCE
PATHOLOGY
Financial problems hitting the family because of MP’s
vehicular accident.
Economic
Educational
Medical
Family is usually self-sufficient, not dependent on other
people for money
Parents are not college graduates themselves but they
strongly encourage their children to finish their
education.
Family as a whole understands the value of education
Family’s 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
Family’s 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 Manila
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 courses
Continuation of schooling as a consequence of the
expenditures they will incur at the end of the medical
admission.
Financial problems limit the family from giving MP the
best possible medical care.
Vehicular Accident
 Type of illness: acute severe
 The greater the severity, the greater the stress
 Lack of emotional preparation
 Lack of financial preparation
 Illness brings out the best, but may also surface pre-existing
dysfunctions
Impact of Illness to the Family
 Stage I - Onset of Illness
 Stage II - Reaction to Diagnosis
 Stage III - Major Therapeutic Efforts
 Stage IV - Early Adjustment to Outcome
 Stage V - Adjustment to the Permanency of the Outcome
Impact of Illness to the Family
 Realization that their daughter sometimes disobeys them
 Centripetal
 Family drawn closer together despite physical distance
 Belief Systems
 “Love offerings” from fellow parishioners
 “God is good to us”
 Family Resiliency and Coping Mechanisms
 Adaptability
 Hard work and cooperation
 Forgiveness
Individuals, families, and communities form a dynamic
support system against the inevitable stresses of life
"Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA.
Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Influences of Resilience
"Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA.
Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Resiliency and the Individual
 From an early age, individuals learn resilient behavior at
home and in their communities.
 Overall, the children’s health and success in school,
relationships, and jobs correlated with:
 their disposition, intelligence, communication skills, and
internal locus of control
 parental warmth and support, and positive relationships with
siblings or other adults
 and support systems in school, church, or community clubs
that rewarded competence and provided a value system.
"Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA.
Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Resiliency and the Family
 Families 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 Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA.
Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
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
Adjustment Phase Steps
 Period preceding a family stressor event
 Prior strains produce changed family demands



poor 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 Steps
 Families 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 itself
 Eliminate the demands by changing the stressor or altering its definition
 Accept 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.
The Family Adaptation Phase
 The occurrence of a crisis is not a signal that the family has
failed or is dysfunctional.
 The adaptation phase is characterized by the family’s
recognition of the need to make change
 Modifying established rules, roles, goals and/or patterns of
interaction.
 Occur in two distinct levels.


Restructuring
Consolidation
Level 1: Restructuring
Level 1: Restructuring
 One 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 family’s
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 family’s problem-solving efforts and structural changes are aimed at:
 management of specific demands
 changes to accommodate demands
 restoring 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: Consolidation
 After 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: Consolidation
 Synergizing: family’s 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
Issues
Legal 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
Conclusion
 MP suffered an acute and severe illness
 The Pradel family is highly functional and resilient
 Poverty may limit the family from giving MP the best
possible treatment
 The family’s religious affiliations provide good support
system
Family Healthcare Plan
Family Member
MP
GP
Screening Tests
Screen for possible
psychiatric morbidities
from the trauma
Screen for other
medical problems as a
consequence of the
vehicular accident
Immunizations/
Chemoprophylaxis
Tetanus toxoid,
Influenza shots and
other prophylaxis
Glucose tolerance tests Influenza shots and
and blood pressure
other prophylaxis
monitoring for
possible DM and HPN
Lifestyle Modification
Reduce stress levels,
exercise, and
refocusing on studies.
Daily exercise, Refocus
on taking care of
daughter while still
being admitted to the
hospital
Counseling Needs
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 accident
Family counseling
relating to feelings
about the financial
burdens of the medical
costs from the accident
Family Healthcare Plan
Family Member
Screening Tests
None indicated
Immunizations/
Chemoprophylaxis
None indicated. As
needed.
JP
None
JP
None
KP
Pediatric
immunizations as
indicated
Pediatric
immunizations as
indicated
Lifestyle Modification
Counseling Needs
Maintain good activity
in work, and in
keeping up relations
with the family
members despite the
working hours
Family counseling
relating to feelings
about the financial
burdens of the medical
costs from the accident
Continue focus on
studies despite
financial constraints
Continue focus on
studies despite
financial constraints
Exploration of feelings
regarding his wife’s
disagreement with him
wanting to work
abroad for better pay
None
None
The End