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BJ’s Last Testimony

BJ’s Last Testimony. Family Medicine Case Presentation 15 January 2010. Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong. Case Background. General Data. 23-year-old Male Iglesia ni Cristo Lives in Manila. Chief Complaint. Cough. History of Present Illness. cough unproductive

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BJ’s Last Testimony

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  1. BJ’s Last Testimony Family Medicine Case Presentation 15 January 2010 Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong

  2. Case Background

  3. General Data • 23-year-old • Male • Iglesia ni Cristo • Lives in Manila

  4. Chief Complaint • Cough

  5. History of Present Illness • cough • unproductive • No associated symptoms (fever, colds, nausea and vomiting, change in bowel movement, dysuria) • No medications taken, no consults done 3 weeks PTA Cough persisted • Persistence of cough • Now associated with chest pain • Heaviness especially when coughing • 3/10 pain scale • No other associated symptoms • No medications taken, no consults done 1 week PTA

  6. History of Present Illness • Unproductive cough • Fever • Intermittent, at Tmax: 38oC • Took paracetamol 500mg once: partial relief • Chest pain 8/10 • More when coughing • Relieved when sitting down • No palpitations, syncope, • Difficulty of Breathing Symptoms persisted 1 day PTA Consult Persistence of symptoms

  7. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions, no pigmentation, no pruritus HEENT: occasional headaches, no redness, no aural/nasal discharge, no neck masses, no sore throat Cardiovascular: no easy fatigability, fainting spells, palpitation

  8. Review of Systems Gastrointestinal: no nausea and vomiting, no loose bowel movements, no constipation Genitourinary: no genital discharge, no pruritus, no problems in urination Endocrine: no polyuria, polydypsia, no heat/cold intolerance Hematopoietic: no easy bruisability, or bleeding

  9. Past Medical History No Hypertension, Diabetes, Asthma, PTB No Cancer, Allergies, Trauma No previous surgeries No previous hospitalizations Not taking any maintenance medications

  10. Family History • History of diabetes • No hypertension, heart disease, cancer, stroke, kidney disease, asthma, or allergies

  11. Personal and Social History • Customer service representative, night shift • Lives alone in own apartment • Multiple unprotected sexual male and female partners • College graduate • Non-smoker • Occasional alcoholic beverage drinker • No substance abuse

  12. Course in the Wards • Initially diagnosed with CAP • Started on cefuroxime and ampicillin • Patient unresponsive, started to have desaturations • Sputum sample turned out to be positive for mycobacterium, and started treatment • Shifted to levofloxacin and carbapenem • Still having desaturations and DOB, moved to ICU

  13. Course in the Wards • In the ICU • Connected to a mechanical ventilator and CPAP • Still unresponsive to treatment • Now suspected to have PCP • Scheduled to have a tracheostomy • Slowly weaned off CPAP • Patient continuously had desaturations, then GCS 3 • Family signed for DNR • Patient expired

  14. Family System

  15. Family System

  16. Family System • Patient • Single, Young adult, Lives alone • Several partners • Parents • Father works as the church minister, • Mother is the children’s primary caregiver • Family • Eldest brother, 2 younger sisters

  17. Impact of Illness

  18. Family Life Cycle • Launching • Goal: Being one’s own person • Secondary task • Differentiation of self from family of origin • Development of peer relationships

  19. APGAR Modified from Smilkstein G: The family  APGAR: A proposal for family function test and its use by  physicians, J . Family Practice 6(6), 1978.  Reprinted by  permission of Appleton and Lange, Inc

  20. Stakeholder Analysis

  21. Other Family Issues • Other family issues • Religion • Iglesia ni Kristo • Father is a minister • Patient’s decision and confidentiality • Only the mother knew • Communication to other family members • Pneumonia not responding to antibiotics • Why the need to confine in an ICU

  22. SCREEM Addressing Disease within a Family Framework

  23. Social-Cultural-Religion-Economic-Education-Medical Tool

  24. MEDICAL ISSUES

  25. ICU: Family Meetings • “Screened” family meetings • Patient’s wishes of confidentiality • Treatment and current status of patient • Focused on issues regarding management of pneumonia • Family members and roles • Mother: confided with father • Father: decision maker • Sisters: support group • Grandmother: active spokesperson

  26. HIV Management • Medical and Psychological • address symptoms • address depression • Social and Legal • Contact tracing and screening • Confidentiality • Difficulty obtaining consent for HIV testing • CD4 count as alternative • Delayed aggressive treatment

  27. Psychosocial Issues

  28. Psychosocial Issues • STIGMA • Societal stigma • Homosexuality: acceptable to society? • Religious stigma • Having the infection as a sign of moral fault

  29. Psychosocial Issues • Financial burden • Issue with HMO coverage for lifestyle-related diseases

  30. Psychosocial Issues • Communication barrier • Psychosocial profile of family • Cultural issues on HIV and homosexuality • DNR and INC doctrines about life • No clear practice on remembering those who died • No doctrine on the issue of DNR

  31. Psychosocial Issues • Bereavement and Acceptance of loss • No clear understanding of how this came about • Difficult to communicate to family members the reason for BJ’s confinement • The issue of communicating his testimony to their community

  32. Family Wellness Plan

  33. Family Wellness Plan • Identify family support roles • Father as source of strength • Iglesiani Cristo community • Delve deeper on grief and bereavement • Family counseling regarding their own feelings towards the loss

  34. Family Wellness Plan • End goal regardless of religion would be the overall acceptance of the situation and the ability to reach a new equilibrium beyond the death of their loved one.

  35. Learnings as a Physician

  36. Learnings as a physician • More than diagnosis and management • RAPPORT • Trust between physician and patient is the key to open up the process of revealing important information

  37. Learnings as a physician • PHYSICIAN = ADVOCATE • Equipped with the Right Tools, Right frame of mind • Responsibility of a physician-advocate • Ensure that patient is well informed • Prevent stigma in healthcare setting • Holistic approach – family is the key

  38. Every physician should be an advocate for each patient. • Equipped with the right tools and the right frame of mind, we begin to realize that illness can be utilized to serve the good of the patient and the family. • Illness is associated with grief and loss of hope, but if we open up our minds and look closer, we will see that Illness also paves the way to unity and healing- for the patient, family, and physician.

  39. BJ’s Last Testimony Family Medicine Case Presentation 15 January 2010 Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong

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