Family Case Presentation

1. Family Case Presentation Abad.Imperial.Javate.Palma.Uy.Valencia

2. To discuss the family profile of Remocaldo family • To establish the family diagnosis using family assessment tools • To present a case of a child with cerebral palsy • To briefly discuss the etiology, pathophysiology and management of cerebral palsy Objectives

3. The Index Case

4. A.R. • 10 y/o • Female • Filipino • Born Again Christian • Angono, Rizal Index Case Profile

5. Hip dislocation • sustained 3 yrs PTC while her mother was stretching her legs • consulted with a GP • advised othropedic consult: cant afford • no medications taken Chief Complaint and HPI

6. Diagnosed case of cerebral palsy with microcephaly • Confirmed at 3 mos • Underwent EEG showing “holes in the brain” • Was recommended to have CT Scan but cannot afford it • Quadriplegic • Physical therapy till 5 y/o • Cannot swallow on her own or expectorate phlegm • Meds: phenobarbital, I grain • Has asthma • Frequently have cough, colds, constipation, and UTI • Bronchopneumonia at 5 y/o • Confined for 1 week in a local hospital Past Medical History

7. also known as congenital cerebral diplegia, static encephalopathy, Little’s disease • a comprehensive diagnostic term used to designate to a group of nonprogressive disorders resulting from malfunction of the motor centers and pathways of the brain • occurs while the brain is under development ( at most 5 years old) • permanent • muscles are not defective Cerebral Palsy

8. Types of Cerebral Palsy Spastic Athetoid Ataxia Characterized by: Tension in muscles; presence of stretch or myotatic reflex, contractures Involuntary, uncoordinated, uncontrollable movements Difficulties in coordination and balance Damaged area: Cortical motor area; pyramidal tract; Extrapyramidal tract; basal ganglia area cerebellum Occurrence: 70% 20% 10%

9. Types of Cerebral Palsy Monoplegia – one limb Hemiplegia – one leg and corresponding arm Diplegia – similar parts on both sides of the body; lower limbs more affected Paraplegia – lower limbs Quadriplegia – tetraplegia - both arms and legs - muscles of trunk, face and mouth

10. Types of Cerebral Palsy

11. Additional: Hearing loss Poor sight Speech defects Learning disabilities Visual or Auditory Agnosia

12. Causes Damage can occur during prenatal, natal, and postnatal period Insufficient oxygen Premature birth Infections in the mother such as: - rubella = German measles - cytomegalovirus = viral infection - toxoplasmosis = parasitic infection Rh disease- incompatibility between blood of mother and fetus

13. Causes Severe jaundice – yellowing of skin and whites of the eye because of bilirubin Brain infections such as : - encephalitis = inflammation of brain - meningitis = inflammation of the membranes covering the brain and spinal cord Physical brain injuries the cause of many individual cases of cerebral palsy is unknown!

14. Symptoms Feeble cry Difficulty in sucking and swallowing Listlessness or irritability Failure to follow normal pattern of motor development ( delayed)

15. Symptoms Apparent preference for one hand before the infant is 12-15 months old Persistence of infantile/ primitive reflexes evidence of mental retardation

16. Hypertension • Asthma • No history of cerebral palsy Family History

17. 25 y/o mother G1P1(1001) • Full term • NSD, local hospital • Attended by an OB-Gyne • Complications: • Difficult birth: mother slipped during 9 mos, baby shifted position • Mother had ecclampsia • Convulsions while giving birth Birth History

18. Breastfed until 1 y/0 • Cannot ingest solid food • Mashed vegetables, rice, sometimes meat Nutritional History

19. Local Health Center • BCG – 1 dose • DPT – 3 dose • OPV – 3 dose • Hep B – 3 dose • Measles – 1 dose Immunization

20. Not at par with age • Cannot move • Cannot talk • Mom claims AR can understand Growth and Development

21. General Survey • conscious, not in cardio-respiratory distress • Vital Signs: • HR – 110/min • RR – 22/min • Temp – 37.2o C Physical Examination

22. Skin: no cyanosis, rashes on dependent areas, particularly in the buttocks • HEENT: normocephalic, pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no nasal discharge, intact tympanic membrane, no tonsillopharyngeal congestion • Neck: supple, no cervical lymphadenopathy • Thorax/Lungs: symmetrical chest expansion, no retraction, resonant, clear breath sounds, no rales, no wheezes Physical Examination

23. Cardiovascular: adynamic precordium, apex beat at 5th LICS MCL, tachycardic with regular rhythm, no murmur • Abdomen: flat, normoactive bowel sounds, no organomegaly, soft,, no mass • Genitourinary: not done • Extremities: full and equal pulses, no edema, Motor 0/5 on all extremities, Sensory and cerebellars cannot be tested Physical Examination

24. Family Assessment Tools

25. AR was born and was later confirmed to have CP AR’s father decided to work for five days without going home Family Lifeline AR’s mother gave birth to AR’s youngest sibling AR’s house was struck by a recent typhoon AR’s parents accepted her condition and tried to give her everything she needs The whole family welcomed the baby and worked harder in order to provide each other’s needs; 2nd child sometimes feels jealous Everyone became accustomed to seeing the head of the family during weekends only AR’s family moved to AR’s paternal grandparents’ house and are staying there indefinitely

28. Family Member Age/ Sex Relation to Patient Occupation • MR 64M Grandfather Unemployed • NR 63F Grandmother Unemployed, Occasional Laundry Washer • BR 34M Father Parking Attendant • MAR 35F Mother Unemployed • KR 9M Brother Student • JR 1M Brother - Family Profile

29. Family Genogram

30. Family with young children (nuclear family) Family Life Cycle

31. APGAR SCORE REASON Adaptation 1 / 2 M: cannot rely on family for everything Partnership 2 / 2 No problems in terms of communication Growth 1 / 1 B: Family supportive but there are a lot of restrictions because of their responsibilities Affection 2 / 2 Everyone feels loved and respected Resolve 2 / 1 G: wants better life for his family APGAR

32. Resource Pathology Social Good relationship within the family and within their community: neighbors supportive and helpful (-) Cultural Proud of who they are and where they came from (-) Religious Born Again: not very religious but follows basic teachings (-) Economic Manages to get by with the income of the family Frequent cause of conflict between AR’s parents, esp. about medications Education Has clear idea on how problems arise and their solution HS graduates only, thus have a hard time looking for high-paying jobs Medical Very patient and diligent in going to health centers and medical missions to avail of free services Heavily relies on health center in their barangay and municipality; these centers are problematic on their own SCREEM

33. Discussion

34. 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

35. Primary Caregiver • Diet modification • Consult with attending pediatric neurologist • Consult with pediatric orthopedic specialist • Linking with new health resources in the community (KHVs/barangay) • Persistent attendance in medical missions, DSWD, governor’s office • Make time for other children • Make time for self to avoid caregiver fatigue Interventions

36. Father • Use time at home to care for AR and support mother • Mediate with extended family if needed • Family • Help with the day-to-day care of AR • Achieve a better diet plan for the family • Provide financial support if possible Interventions

37. Thank You