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Family Case Presentation

Family Case Presentation. Intern Ongkeko Intern Rogacion Intern Samson. Outline. Index patient (Case) -hx pe, Assessment, Plan (kasama yung sa CAMP)!! Family Assessment Tools Family Identification Composition Social History Community Neighborhood Health history Roles in the family

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Family Case Presentation

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  1. Family Case Presentation Intern Ongkeko Intern Rogacion Intern Samson

  2. Outline • Index patient (Case) -hx pe, Assessment, Plan (kasama yung sa CAMP)!! • Family Assessment Tools • Family Identification • Composition • Social History • Community Neighborhood • Health history • Roles in the family • Genogram • Family life cycle (Stage) • APGAR • Family Map • SCREEM • Family timeline • Impact of illness on the family • Rapid community med check • Individual Health Plan • Family Wellness Plan • EBM yak!

  3. Index Patient • The patient is J.V. a 30-year old female from Nagsaulay, San Juan, Batangas. She is a right-handed, Roman Catholic, housewife. • Chief Complaint: Referred by BHW for medical check-up

  4. History of Present Illness • Patient Profile: The patient is a non-asthmatic, non-diabetic and non-hypertensive. She was previously diagnosed as a case of polio during childhood. • During a previous session in the LHC, a BHW asked his patient to be seen. Hence this consult.

  5. Review of Systems • General: (-)fever, (-) weight loss, (-) malaise, (-) anorexia • Integumentary: (-) easy bruisability, (-) rashes • HEENT: (-) colds (-) headache, (-) blurring of vision, (-) nasoaural discharge, (-) loss of hearing, (-) dysphagia, (-) dysphonia • Respiratory: (-) cough, (-) hematemesis, (-) hemoptysis • Circulatory: (-) easy fatigability, (-) chest pain, (-) palpitations, (-) orthopnea, (-) PND • Digestive: (-) abdominal pain, (-) nausea/vomiting, (-) diarrhea/constipation • Urinary System: (-) dysuria, (-) oliguria, (-) hematuria • Nervous: (-) decreased sensorium, (-) behavioral change, (-)seizures • MSK: (-) pain, (-) swelling, redness, warmth

  6. Past Medical History • as above • s/p bitubal ligation (2009)

  7. OB-Gyne History • Menarche at 13 years old, periods occurring in regular monthly intervals, lasting for 2-3 days, consuming 2-3 moderately soaked cloth pads per day, (-) dysmenorrhea • She is a G4P4 (4004) mother. During her pregnancies, she had regular PNCU’s c/o the LHC. All her children were FT delivered via SVD assisted traditional birth attendant without perinatal complications.

  8. Family Medical History • See later slides • No history of DM, hypertension, TB, goiter, cancer • (+) Osteoporosis - maternal grandmother • No other members with similar problems as the patient

  9. Personal & Social History • The patient is a 30-year old housewife. • She was able to reach Grade 1 but is illiterate and has no formal job experience. • No vices (smoking, alcohol, illicit drugs) • Usual diet is fish • Husband is a fisherman who is presently living with his mother. • They have four children. The first of whom also lives with her husband’s mother. • They are first cousins!! • They live in a house made of light materials (dried coconut leaves and bamboo) • Source of water is a public artesian well which is 30m from their home • They do not have their own toilet. They use the rest room of their uncle, 15 meters from their home.

  10. Physical Exam • General Survey: • Awake, conscious, coherent, not in cardiorespiratory distress • Vital Signs: • BP 110/70 • HR 88 bpm • RR 19 bpm • Temp 37.0°C • Anthropometrics • Height: 152 cm • HEENT • Pink conjunctivae, anicteric sclerae, no cervical lymphadenopathy, (-) neck vein engorgement, no anterior neck mass, no nasal or aural discharge, (-) tonsillopharyngeal congestion, (+) visible cerumen • Chest/Lungs: • Equal chest expansion, clear breath sounds, no rales/wheeze/crackles • CVS: • Adynamic precordium, (-) heaves/thrills, Apex beat at 5th ICS L MCL, (-)murmurs • Abdomen: • Flat, soft, not distended, (+) postsurgical scar normoactive bowel sounds, (-) masses/tenderness • Skin/Extremities: • Full and equal pulses, pink nailbeds, dry skin with good skin turgor, (-) edema/cyanosis/clubbing, capillary refill time < 2 seconds, No atrophy • True Leg Length: R: 31in L: 30in • Neurologic: • GSC 15, oriented to time, place, and person; intact cranial nerves I-XII (decreased hearing acuity, AS), no sensory deficits, 5/5 motor strength on all extremities, +2 deep tendon reflexes, no babinski reflex, no cerebellar signs • OPHTHA: • VA: OD: can read fine print; OS: counting fingers at 3 feet • (+) leukocoria OS, pupils equally brisk and reactive to light; full EOMs, (+) visual field defects in inferonasal quadrant, OS

  11. Assessment • Congenital cataract, etiology? • Polio (EDIT ME!!!!!!!) • ASSESSMENT FROM CAMP • s/p bitubal ligation (2009)

  12. PLAN • PLAN FROM CAMP • Diet as tolerated • Wear thicker slippers on the left • Advised on ophthalmologist consult • Daily bath and oral hygiene • Maintain a clean home and surroundings

  13. Family Identification • Insert Pic

  14. Family Identification • Jocelyn-mother • Alberto-father • Jema Rose- eldest • John Carlo- second • John Lloyd- third • Anika- youngest

  15. Family Identification • Community Neighborhood • Look at Chionglo’s community update

  16. Family Identification • Social History • JV was originally from Bicol and transferred to San Juan, Batangas when she was 22 years old. • JV and Alberto are first cousins. Their fathers are brothers. The family is still hesitant to talk about the history of JV’s family.

  17. Health History

  18. Roles in the Family • Breadwinner- Alberto • Decision-maker- Lilia • Handles budget- Alberto/Lilia • Disciplinarian- JV • Primary Caregiver- Lilia

  19. Genogram

  20. Family Life Cycle Stage • Family with Young Children

  21. Family APGAR • JV

  22. Family APGAR • Antonio

  23. Family APGAR • Lilibeth

  24. SCREEM

  25. SCREEM

  26. SCREEM

  27. Family Timeline • WADAHECK!!!!

  28. Impact of Illness on the Family

  29. Rapid Community Medicine Check

  30. INDIVIDUAL HEALTH PLANS

  31. FAMILY WELLNESS PLAN

  32. JOURNAL APPRAISAL

  33. DILEMMA

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