Family Case Presentation University of the Philippines – Philippine General Hospital Department of Family and Community

1. Family Case PresentationUniversity of the Philippines – Philippine General HospitalDepartment of Family and Community Medicine Payumo, Pelayo, Quiogue, Rodriguez

2. Specific Objectives • To formulate, implement, and discuss a patient-centered health management plan. • To describe the family psychodynamics using widely used family assessment tools. • To discuss the social environment, its resources, and hindrances to a successful wellness plan • To be able to formulate family wellness plans • To critically appraise a related journal article and show its application to the case/community

3. Outline • Index Case Profile • The Family • Family Wellness Plan • Journal

4. INDEX CASE PROFILE

5. General Data • EdithaAbanilla • 40 y.o./female • Single • Right-handed • Roman Catholic • Unemployed • Balacbacan, LaiyaAplaya, San Juan, Batangas

6. Chief Complaint Uncontrolled Blood Pressure

7. History of Present Illness 2003 Consult Private MD in Batangas Work ups Done Occasional Headache HYPERTENSION Amlodipine(Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID Left Upper Extremity Numbness

8. History of Present Illness 2007 Weight Loss HYPERTHYROIDISM Consult at Capitol Medical Center Work ups Done Easy Fatigability RAI x 1 dose Levothyroxine (Thyrax) 150 mcg OD Heat Intolerance & sweating Difficulty Falling Asleep Dysphagia Palpitations

9. History of Present Illness 2007 2008 2009 Amlodipine(Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID Compliance? Last follow up was on January 2009 ASYMPTOMATIC Regular Follow up Levothyroxine (Thyrax) 150 mcg OD

10. History of Present Illness June 2009 Amlodipine(Norvasc) 5 mg OD Metoprolol (Neobloc) 50 mg BID ASYMPTOMATIC Compliance? UNCONTROLLED Levothyroxine (Thyrax) 150 mcg OD BLOOD PRESSURE Usual BP = 140/90 Highest BP = 160/100

11. Review of Systems • General: no weight loss, (+) weight gain, undocumented (about 30% in 2 years) no loss of appetite, no fever, no night sweats • Skin: No rash, no lumps, no dryness, no pruritus, no changes in hair or nails • HEENT: occasional diffuse headache esp during hot weather, no dizziness, blurring of vision, no tinnitus, no dysphagia, no gum/nose bleeding • Respiratory: no hemoptysis, no cough, no colds, no dypnea • Cardiovascular: no chestpain, no palpitations, no orthopnea, no easyfatigability, no PND • GIT: no abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, no melena, no hematochezia • GUT: no dysuria, no oliguria, no hematuria, no urinaryfrequency • Hema: no excessive bleeding, no easy bruisability • Endocrine: no polyuria, no polyphagia, no polydipsia, no heatorcoldintolerance, no excessivesweating • MSS: no myalgia, no arthralgia • Neuro: no seizures, no loss of consciousness, no paresthesias, no paralysis

12. Past Medical History • 2008 – admitted at a clinic in San Juan for 1 day for correction of hypokalemia • No Bronchial Asthma • No Diabetes Mellitus • No known allergies • No PTB

13. Family Medical History • (+) DM – Father, sister • (+) Heart Disease – Mother • (+) CVD – Sister • (+) HPN – Sister • (-) PTB • (-) Bronchial Asthma • (-) liver/kidney problem

14. Menstrual/Sexual/OB History • Menarche at 13 yrs old • Regular Monthly Period, lasting for 3 days, use of 3-4 ppd moderately soaked • Occasional dysmenorrhea • No previous sexual contact • G0

15. Personal and Social History • High school graduate • Nonsmoker • Nonalcoholic beverage drinker • Denies illicit drug use • Lives with brother and niece • Unemployed, supported by a brother who works abroad • Diet consists mostly of vegetables

16. Physical Examination • General: Conscious, coherent, not in cardiorespiratory distress • BP: 140/80 HR: 66 RR: 18 Temp: 36.7 Wt: 78 kg Ht: 157 cm BMI: 31.6 • Skin: good skin turgor, no pallor, no cyanosis • HEENT: anictericsclerae, pink palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal congestion, no palpable cervical lymphadenopathy, distended neck veins, no thyromegaly • CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds • HEART: adynamicprecordium, normal rate, regular rhythm, apex beat at the 5th ICS, LMCL, S1>S2 at the apex, S2>S1 at the base, no murmur • ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no organomegaly • EXTREMITIES: no edema, no cyanosis, full & equal pulses

17. Neurologic Examination • Awake, oriented to time, person and place • Cranial Nerves: CN I – can smell CN VIII – can hear CN II – (+) ROR, OU CN IX, X – gag intact CN III, IV, VI – EOM intact CN XI – good shoulder shrug CN V – bicorneal reflex intact CN XII – tongue midline CN VII – no facial asymmetry 100% ++ ++ 100% 5/5 5/5 100% 5/5 100% ++ ++ 5/5 DTR MOTOR SENSORY

18. ASSESSMENT • Hypertension Stage II, Uncontrolled • Obese Class I • S/P RAI ablation x hyperthyroidism

19. PLAN • Dianostics • FBS, Urinalysis, Serum Crea, K, Lipid Profile, 12 L ECG • TSH • Therapeutics • Shift to Losartan + HCTZ 50/12.5 1 tab OD • Cont Levothyroxine 150 mcg 1 tab OD

20. PLAN • Non-pharmacologic • Low fat, low salt diet • Daily exercise (brisk walking 30 mins OD) • BP Diary • Advised follow up to PMD • Advised Ophtha Consult

21. FAMILY ASSESSMENT

22. Outline I. Family structure and function • Genogram • Type of Family • Family Identification • Stage in the Family Life Cycle • Timeline II. Family Psychodynamics • Mapping • Family Psychosocial Data • APGAR • SCREEM

23. FAMILY GENOGRAM

24. ABANILLA-SIGANAY FAMILY JULY 2009 ABANILLA SIGANAY ALFREDO, 65 (1993) CRISCENCIA, 73 (2003) 4 CHITO 38 JERRY 35 SUSAN 46 EDITH 40 PACIFICO 64 ANGELITO 56 MERLYN 62 3 Siblings VANGIE 41 3 3 4 2 KIM 13 Diabetes Mellitus Hypertension Heart Disease Mild Stroke

25. Type of Family • Structure: extended-family • Ordinal position: third to the last child • Family socio-economic class patterns: middle-class • Family set-up: democratic

26. Family Identification • Composition • Ate Edith: third to the youngest of 10 children

27. Family Identification • Composition • KuyaChito: second to the youngest in the family

28. Family Identification • Composition • Kuya Jerry: youngest child of Abanilla family, currently in Canada • Kim: 13-year-old daughter of KuyaChito

29. Family Identification • Abanilla home has • one bedroom • a living-room with television and stereo component • a dining area with one table, • a kitchen and a sink • a dirty kitchen outside with 2 chained dogs named Santino and Ampon

30. Social History • Ate Edith graduated from Laiya National High School. She worked for 3 years in a fruit store in San Pablo. She then transferred to a grocery in Poblacion for 1 year before staying in Laiya with her brother Jerry and their niece Kim. • Prior to owning a resort, they had a fishing business for 10 years. Ate Edith now busies herself with the resort and with collecting money for electricity.

31. Social History • Kuya Jerry is an HRM graduate who later studied Culinary arts. He financed his studies by having his own catering business. He has lived with his sister Edith but has recently left to work in Canada as a chef. • He was the one who started plans of owning a resort and now is its main financier.

32. Social History • KuyaChito finished 3rd year HS, after which he worked as a waiter in Super Ferry for 3 years. It was where he met his wife, who was then his supervisor. • He later transferred to work at Kabayan resort in Laiya. He was an employee there for 10 years and recently was assigned at KaffeBrako as a barista.

33. Social History • Kim is a 2nd year HS student. She has stayed with Ate Edith and Kuya Jerry since she was a child. Her father has lived with them for 6 years now. Her mother works as a supervisor in a Makro store in Dubai; she goes home every 3 years.

34. Community Neighborhood • SitioBalacbacan in LaiyaAplaya is home to a number of beach resorts, composed of several houses owned by common families. • Fishing is the community’s main livelihood. Early morning each day, fishermen bring ashore their catch for the sitio’s consumption. As such, everyday meals usually consist of fish-based viands. • A recent issue of land ownership in Balacbacan threatens its residents’ homes and livelihood.

35. Community Neighborhood • Balacbacan Residents • They are usually composed of each one’s relatives, although they remain in good terms with the few people who are not related to them. • They are hospitable and friendly, and are used to having visitors and tourists in their community.

36. Family Life Line 1992: Death of Ate Edith’s Father 2000: Kim’s mother left 2003: Death of Ate Edith’s Mother 2005: Island Sky Resort 2007: Relocation of People in Balacbacan June 2009: Kuya Jerry left for Canada

37. Family Life Cycle Stage • Since the three siblings share a home with Kuya Jerry’s 13-year-old daughter for the past few years, they can be said to be in the stage of transition from families with young children to families with teenagers/ adolescents. • For Ate Edith and Kuya Jerry, they had adjusted their role as siblings to a role of parenting as help to their brother KuyaChito. They shared with him the task of child rearing, in addition to financial and household tasks.

38. Family Life Cycle Stage • With Kim now developing as a teenager, the siblings must learn to be flexible regarding understanding certain changes in her. Although physical independence is not yet an issue, psychological independence may now be budding. Sex education should also be given importance, as early pregnancy in not uncommon in Laiya. • Ate Edith may also be dealing with career issues, with the current threat of land ownership in Balacbacan.

39. Family Life Cycle Stage • The Abanilla family had faced their parents’ death earlier in the cycle. Thus, their concern is concentrated to their generation and the younger ones. • Chronic illness, i.e., hypertension, has also become a challenge to Ate Edith, again earlier than expected in the cycle.

40. FAMILY PSYCHODYNAMICS

41. FAMILY MAP

42. ABANILLA-SIGANAY FAMILY JULY 2009 ABANILLA SIGANAY ALFREDO, 65 (1993) CRISCENCIA, 73 (2003) 4 CHITO 38 JERRY 35 SUSAN 46 EDITH 40 PACIFICO 64 ANGELITO 56 MERLYN 62 3 Siblings VANGIE 41 3 3 4 2 KIM 13

43. Family Dynamics • The Abanilla family is functional. • The Abanilla siblings meet on special occasions at Ate Edith’s house in Balacbacan. • The family faced great challenges upon the death of their father, followed years after by the death of their mother. Their eldest sibling became their leader and they coped with death as a family. • Ate Edith’s home is now composed of her, KuyaChito and his daughter Kim, and Kuya Jerry. They have a good relationship and currently have no source of conflict.

44. Psychosocial Data • Communication patterns • The Abanilla family’s communication style can be said to be receptive, occasionally with some distancing. • The siblings’ separate family lives sometimes make it difficult for them to ask/give help from/to each other. • Ate Edith’s home in Balacbacan is more of the receptive type, as Kuya Jerry finds time to regularly talk to them although he is currently in Canada.

45. Psychosocial Data • Leadership • This role belongs to the family’s eldest, KuyaPacifico. • Age is a factor here. • It was their KuyaPacifico who helped the family cope with their parents’ death.

46. Psychosocial Data • Breadwinner • This role is shared by Ate Edith, who manages their resort, and Kuya Jerry, who now works in Canada as a chef. They also help with financing Kim’s studies.

47. Psychosocial Data • Authority • According to Ate Edith, authority is conferred mainly on Kuya Jerry.

48. Psychosocial Data • Primary caregiver • Ate Edith is the main care-giver of the family since the wife of KuyaChito is abroad

49. Psychosocial Data • Family’s present priorities • Maintenance of the resort and their corresponding land ownership is the family’s main priority, especially with the current issue in Balacbacan regarding property rights.

50. FAMILY APGAR