Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina

1. Family Case Presentation Baslar, Isa Belmonte, Celeste Brillante, Christie Bulatao, Jose Cheng, Monina

2. GENERAL OBJECTIVE • To re-evaluate a patient currently enrolled in the UST-DFM Family Health Care Program for continuance of care

3. 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

4. GENERAL DATA • F. L. • 81 years old • Female • Single

5. HISTORY OF PRESENT ILLNESS CONSULT

6. 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

7. 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

8. 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

9. FAMILYHISTORY • (-) asthma • (-) allergy • (-)PTB • (+)Kidney disease – sister • (+) HPN – sister • (-) DM • (-) Cancer

10. 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

11. 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

12. 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

13. 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)

14. ASSESSMENT OF INDEX PATIENT • Osteoporosis • Fracture, R hip • Senile Cataract, OU • Dextroscoliosis

15. FAMILY ASSESSMENT

16. UST BARLIN ST P. NOVAL X ELOISA ST ADELINA ST DAPITAN

17. STAIRS CR PATIENT’S ROOM

18. CHAIR CHAIR TV WINDOWS TABLE E.FAN PATIENT’S BED CABINET

19. ENVIRONMENTAL HISTORY • Concrete type, 3-storey building • Patient rents an 8 bedroom house • She occupies one room and sublets the others • Fairly clean , well-ventilated and well-lit • Electricity provided by Meralco • Water source is tap water • Drinking water is commercially available 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

20. FAMILY TREE Laganzua Family 1209 A.J. Barlin St Sampaloc, Manila December 3, 2009 Rufo , 72 Inocencia,100 Jose,30 +, * Adelaida, 27 Lorenza,81 Andrea,22 Jesus,60 Asuncion, 60 Carmelita,62 Esteban,65 Henry Odelon Clarissa Vivian Serrina MeAnne,33 Ariel,31 Anthony Mae Flora, 81 Seth, 6 Michael,35 Arlene,32 + = kidney disease * = HPN Vaughn Matthew,2

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

23. 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

24. ECONOMIC PROFILE Income PhP 22,ooo Expenses • FOOD 10,000 • EDUCATION 3,000 • MEDICATION 1,000 • MISCELLANEOUS • (electricity, water, house rent) 4,000__ TOTAL EXPENSES: 18,000 Savings: 4,000

25. HIGHLY FUNCTIONAL

28. MODIFIED CAREGIVER STRAIN INDEX • Me-anne Laganzua • Madalas- 2 • Minsan – 1 • Halos Hindi – 8

29. FAMILY LIFE CYCLE STAGE Family with young children- starts with pregnancy for the 1st child to emergence of adolescents.

30. FIRST ORDER CHANGE • . • . • . • . • . • Supplying adequate space , facilities and equipment for the expanding family • Meeting predictable and unexpected costs of family life with small children • Sharing responsibilities within the extended family and between members of the growing family • Maintaining mutually satisfactory sexual relationship and planning for the future children • Creating and maintaining effective communication system in the family • Cultivating the full potentials of relationship with relatives within the extended family • Tapping resources, serving needs, and enjoying contracts outside the family • Facing dilemmas and reworking philosophies

31. SECOND ORDER CHANGE • . • . • . • Accepting marital system to make space for children • Taking on parenting role • Re-alignment of relationship with extended family to include parenting and grandparenting roles

32. FAMILY ASSESSMENT Family with young children – UNILATERALLY EXTENDED

33. STAGE IN THE ILLNESS TRAJECTORY STAGE V: • Adjustment to the permanency of the outcome.

34. 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

35. PATHOPHYSIOLOGY Fractures in the Elderly • Osteoporosis • Remodeling does not occur in trabecular bone, therefore metaphysis is prone to fracture • Pathologic Fractures • Decreased muscle mass • Postural changes • Decreased vibration sense and proprioception • Increased reaction time • Visuoperceptual decline • Impaired mobility

36. PRIMARY PREVENTION SECONDARY PREVENTION Fractures in the Elderly • History and Physical Examination • FRAX and DEXA • Dietary modification and exercise regimen • Review of medications that may cause dizziness, syncope, etc • Regular eye exams • Safer home: • Slip guards and hand rails • Removing objects on floor • Storing items in easy to reach cabinets • Improve lighting in the home • Goal  rapid return to activities for independent living • Diagnosis • History and PE • X-ray • CT scan • Treatment • Immobilization • Surgical stabilization • Joint replacement National Center for Injury Prevention and Control  CDC Injury Center

37. TERTIARY PREVENTION Fractures in the Elderly • Stiffness – daily active or passive ROM exercises of adjacent joints • Contractures – periodic changes in position • Swelling – elevation of limb • Pressure sores – daily inspection and padding of contact points • Functional impairment – gradual re-introduction of ADLs Merck Manual of Geriatrics. Fractures

38. FRAX: WHO Fracture Assessment Tool

39. Senile Cataract a vision-impairing disease characterized by gradual, progressive thickening of the lens It is one of the leading causes of blindness in the world today Age is an important risk factor for senile cataract.

40. Work-up Clinicals • Laboratory Studies- screening process to detect coexisting diseases (eg, diabetes mellitus, hypertension, cardiac anomalies) • Imaging Studies- ocular imaging studies (eg, ultrasound, CT scan, MRI) History- decrease visual acuity, increase glare, mild to moderate myopia, monocular diplopia P.E.- slit lamp examination

41. Treatment • The definitive management for senile cataract is lens extraction. • No drug is available that has been proven to prevent the progression of senile cataracts. Medical therapy is used preoperatively and postoperatively to ensure a successful operation and subsequent visual rehabilitation.

42. Dextroscoliosis Scoliosis is a medical condition in which a person's spine is curved from side to side or front to back, and may also be rotated Dextroscoliosis is a scoliosis with the convexity on the right side

43. Symptoms • Pain • Uneven musculature on one side of the spine • A rib "hump" and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracicscoliosis • Uneven hip and shoulder levels • Asymmetric size or location of breast in females • Unequal distance between arms and body • Clothes that do not "hang right", i.e. with uneven hemlines • Slow nerve action (in some cases)

44. Investigation Standard method for assessing the curvature quantitatively is measurement of the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved

45. Management The conventional options are, in order: 1. Observation 2. Bracing - for example the Milwaukee brace 3. Surgery

46. FAMILY HEALTH CARE PLAN: Index Patient

47. FAMILY HEALTH CARE PLAN: Other family members

48. THANK YOU!!!