Baslar, IsaBelmonte, CelesteBrillante, Christie

Bulatao, JoseCheng, Monina

Family Case Presentation

GENERAL OBJECTIVE

To present a patient with osteoporosis, Fracture, Right hip

SPECIFIC OBJECTIVESTo identify medical, psychological, social and

economic problems of the index patient and his family

To analyze the family 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

GENERAL DATA

F. L. 81 years old female Roman Catholic Filipino Single Store owner DOB:4/23/28

HISTORY OF PRESENT ILLNESS

CONSULT

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 HISTORYNon-smokerNon-alcoholic beverage drinkerDenies illicit drug use

Diet: Mixed diet (vegetables, fruits, meat)Store owner, retired teacherBS Education graduateDoes 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 PTBNo operations(+) allergy to medicolImmunization: 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 36.7C• 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,

non-tender, 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

Clock Drawing Test Geriatric Depression Scale: 3 (normal)

ASSESSMENT OF INDEX PATIENT

OsteoporosisFracture, R hipSenile Cataract, OUDextroscoliosis

FAMILY ASSESSMENT

UST

DAPITANP. N

OVAL BARLIN ST

ELOISA ST

ADELIN

A ST

X

STAIRS

PATIENT’S ROOM

CR

PATIENT’S BED

TV

CABINET

CHAIRCHAIR

E.FAN

TABLE

WIN

DO

WS

ENVIRONMENTAL HISTORYConcrete type, 2-storey buildingHouse-rented patient rents 8 bedrooms (patient occupies only one room and

rents the others)Fairly Clean , well-ventilated and well-litElectricity from MeralcoWater source from NAWASA but drinking water - purified waterToilet Type- flush, Drainage is goodRegular waste disposal, no segregation but regularly collectedDo not have pets but there are many stray animals and pests in

the neighborhoodArea is accessible by- taxi, jeep, tricycle

FAMILY TREE- Laganzua Family

Lorenza,81

Jose,30

Adelaida, 27 Andrea,22 Jesus,60 Asuncion, 60

Flora, 81

Clarissa Vivian Serrina

Henry Odelon

Carmelita,62 Esteban,65

Anthony Mae MeAnne,33 Ariel,31

Seth, 6 Michael,35 Arlene,32

Vaughn Matthew,2

Rufo , 72 Inocencia,100

Family Structure• Type of Family- Unilaterally extended• Ordinal Position: Third• Social Class Pattern : Low Income Family• Family Set-Up: Democratic

FAMILY PROFILE

AGE/SEX

RELATION TO HEAD

EDUCATIONAL ATTAINMENT

OCCUPATION CURRENT HEALTH STATUS

Flora 81/F Aunt B.S. Education graduate

Retired teacher, store owner

OsteoporosisFracture, R hipSenile Cataract, OUDextroscoliosis

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 PROFILEIncome PhP 22,000Expenses

FOOD 10,000 EDUCATION 3,000 MEDICATION 1,000 MISCELLANEOUS

(electricity, water, house rent) 4,000__ TOTAL EXPENSES: 18,000Savings: 4,000

Alloc ation of inc ome

F oodE ducationMedicationmiscellaneous

HIGHLY FUNCTIONAL

FAMILY APGAR 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, 4-7 moderately dysfunctional, <4 severely dysfunctional) SCALE: 2-Palagi, 1-Paminsan-minsan, 0-Halos hindi

9 8

PARAMETER STRENGTH WEAKNESSSOCIAL [ / ] Open intrafamilial lines of

communication[ / ] Absence of animosity/rivalry[ / ] Healthy/supportive intrafamilial relationships[ / ] Healthy/supportive extrafamilial relationships

[ ] Lack of intrafamilial lines of communication[ ] Presence of animosity/rivalry[ ] Unhealthy intrafamilial relationships[] Unhealthy 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.)

[ ] Presence of some beliefs/practices that are unacceptable to our culture or negatively affect way of living (Specify these practices):

RELIGIOUS [ / ] Spirituality is positively influencing way of life[ / ] Practicing one’s faith, enduring because of his faith

[ ] Spirituality is negatively or not at all influencing way of life[ ] Not practicing one’s faithOthers: Religious activity is not a significant aspect of their family life

PARAMETER STRENGTH WEAKNESS

EDUCATIONAL [ / ] Level of education is not a hindrance to achievement, livelihood, success[ / ] Level of education facilitates comprehension of most challenging circumstances

[ ] Level of education is a hindrance to achievement, livelihood, success[ ] Level of education hinders comprehension of most challenging circumstances

ECONOMIC [ / ] Ability to allocate funds appropriately[ / ] Ability to make ends meet most of the time

[ ] Inability to allocate funds appropriately[ ] Inability to make ends meet most of the time

MEDICAL [ / ] Good compliance with medical management[ ] Timely and appropriate medical consultation[ / ] Aware and practices wellness and environmental sanitation.

[ ] Poor compliance with medical management[ /] Inappropriate medical consultation[ ] Not aware / does not practice wellness and environmental sanitation

MODIFIED CAREGIVER STRAIN INDEX

Me-anne Laganzua• Madalas- 2• Minsan – 1 • Halos Hindi - 8

FAMILY LIFE CYCLE STAGE

Family with young children- starts with pregnancy for the 1st child to emergence of adolescents.

FIRST ORDER CHANGE1. Supplying adequate space , facilities and equipment for the

expanding family2. Meeting predictable and unexpected costs of family life with

small children3. Sharing responsibilities within the extended family and

between members of the growing family4. Maintaining mutually satisfactory sexual relationship and

planning for the future children5. Creating and maintaining effective communication system in

the family6. Cultivating the full potentials of relationship with relatives

within the extended family7. Tapping resources, serving needs, and enjoying contracts

outside the family8. Facing dilemmas and reworking philosophies

.

. .

.

.

SECOND ORDER CHANGE

1. Accepting marital system to make space for children

2. Taking on parenting role3. 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 PROBLEM RECOMMENDATIONSWELLNESS {promotive, preventive}

Patient maintains a balanc dietLast immunization: unrecalled

For immunization: Tetanus, Pneumococcal, InfluenzaEncourage ROM exercises daily

MEDICAL Osteoporosis with Fracture , R hip Senile Cataract, OUWith episodes of BP elevations

For Rehabilitation therapyFor orthopaedic consultFor Ophthalmologic consultFor Hypertensive work-up

PSYCHOSOCIAL 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.

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 FAMILY MEMBER

PROBLEM RECOMMENDATIONS

WELLNESS {promotive, preventive}

Me-AnneArielSeth

Maintain balance dietUpdate immunizationDaily exercise

MEDICAL Me-Anne

Seth

s/p spine surgery for arachnoid cyst(?) June 2009Asthma- last attack unrecalled

For ff-up with Neurology

Avoid triggers

PSYCHOSOCIAL Me-Anne 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.