Sie sind auf Seite 1von 51

University of Perpetual Help

Dr. Jose G. Tamayo Medical Center


Sto. Nio, Bian, Laguna

Department of Family and Community Medicine

Family Case
Janel Enriquez
Weshley Manarin
Charles Lao
May 20, 2016

The house
Semi concrete house
1 bedroom
1 comfort room
Living room
2 electric fan
1 TV
Dining room
4 windows
1 gas stove

open drainange
Good ventilation
Toilet: flushed toilet
Garbage disposal: daily
collection
Water source: laguna
water & distilled water

Lives with husband,


son and his family
Easy access with the
neighborhood and
public transportation

FAMILY STRUCTURE
Structure:
Unilaterally Extended family
Family socio-economic class patterns:
Middle-class
Family set-up:
Democratic

FAMILY LIFE CYCLE

Family in Later Years

PSYCHOSOCIAL DATA
Leader

Juanito

Breadwinner

John

Primary
Caregiver

Annaliza

GENERAL DATA
M.A.
/ female/ Married
Roman Catholic
Filipino
October 19, November, 4,

1936
Pampanga
Bian, Laguna

CHIEF COMPLAINT

Right leg pain

Informant : Patient

%Reliability: 90%

HISTORY OF PRESENT ILLNESS


1 week PTC
(+) right arm weakness
(+) right leg pain, squeezing, non radiating,
5/10
No medications taken, no consult done.

HISTORY OF PRESENT ILLNESS


5 days PTC
Symptoms persisted
Massaged right leg with unrecalled type of
herbal oil
Afforded temporary relief
No associated symptoms such as numbness,
limitation of movement nor weakness.
No medications taken, no consult done.

HISTORY OF PRESENT ILLNESS


Few hours PTC
(+) right leg pain persisted, 2/10 painscale
Sought consult in this institution for further
evaluation and management

PAST MEDICAL HISTORY


(+) DM 54 years old
Glicazide 30mg/tab compliant

(+) hypertension 64 years old


Clopidogrel Bisulfate
Tremazitide
Vitamin B complex

(+) Hospitalization Hypertension


( increase BP 200/100)
(-) Allergy to drugs

FAMILY HISTORY
(+) Hypertension Paternal
(+) CVA Both
(+) PTB Maternal

FAMILY
ASSESSMENT

FAMILY GENOGRAM

Agido, 72 y/o

ALCAZAR FAMILY
Bian, Laguna
May 19, 2016
Secundina, 82 y/o

Cuenco,

Capili

Amorel, 55 Lebrada 68Evangelita, 83


Felito 75Ester, 74Carmela, 65
Lotgardo, 83

Adoracion 80

Juanito 78

Dong, 65Augusto, 60

Mercedita , 79

June 3 , 1962

Jonathan, 53

John, 48

Annaliza, 48 Jose, 45

LEGEND:
Informant: Mercedita
Informant: 90%

-DM
-Cancer/Colon
- Hypertension
Nathaniel, 23

Patrick, 21

Kabella, 19

FAMILY APGAR
(Daughter-in-law)
APGAR

ADAPTATION

QUESTIONS

Akoy nasisiyahan dahil nakakaasa ako ng

Almost

Some of

Hardly

always

the time

ever (0)

(2)

(1)

tulong saking pamilya sa oras ng problema


PARTNERSHIP

Akoy nasisiyahan sa pakikipagtalakayan sa

akin ng aking pamilya tungkol sa aking


GROWTH

problema.
Akoy nasisiyahan at ang aking pamilya ay

tinatanggap at sinusuportahan ang aking mga


nais na gawin patungo sa bagong landas para
sa aking ikauunlad.
AFFECTION

Akoy naisisiyahan sa paraang ipinadadama ng

aking pamilya ang kanilang pagmamahal at


nauunawaan ang aking damdamin katulad ng
galit, lungkot at pag-ibig
RESOLVE

Akoy nasisiyahan na ang aking pamilya at ako

ay nagkakaroon ng panahon sa isat isa.


10 = Highly Functional Family

FAMILY APGAR
(Husband)
APGAR

ADAPTATION

QUESTIONS

Akoy nasisiyahan dahil nakakaasa ako ng

Almost

Some of

Hardly

always (2)

the time

ever

(1)

(0)

tulong saking pamilya sa oras ng


PARTNERSHIP

problema
Akoy nasisiyahan sa pakikipagtalakayan

sa akin ng aking pamilya tungkol sa aking


GROWTH

problema.
Akoy nasisiyahan at ang aking pamilya

ay tinatanggap at sinusuportahan ang


aking mga nais na gawin patungo sa
AFFECTION

bagong landas para sa aking ikauunlad.


Akoy naisisiyahan sa paraang

ipinadadama ng aking pamilya ang


kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit,
RESOLVE

lungkot at pag-ibig
Akoy nasisiyahan na ang aking pamilya
at ako ay nagkakaroon ng panahon sa
isat isa.

FAMILY APGAR
(Patient)
APGAR

ADAPTATION

QUESTIONS

Akoy nasisiyahan dahil nakakaasa ako ng

Almost

Some of

Hardly

always (2)

the time

ever

(1)

(0)

tulong saking pamilya sa oras ng


PARTNERSHIP

problema
Akoy nasisiyahan sa pakikipagtalakayan

sa akin ng aking pamilya tungkol sa aking


GROWTH

problema.
Akoy nasisiyahan at ang aking pamilya

ay tinatanggap at sinusuportahan ang


aking mga nais na gawin patungo sa
AFFECTION

bagong landas para sa aking ikauunlad.


Akoy naisisiyahan sa paraang

ipinadadama ng aking pamilya ang


kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit,
RESOLVE

lungkot at pag-ibig
Akoy nasisiyahan na ang aking pamilya
at ako ay nagkakaroon ng panahon sa
isat isa.

FAMILY SCREEM
SCREEM
SOCIAL

RESOURCES

Patient was able to socialize in their community and


join community activities and events
Well-balanced lines of communication with other
members of the community

CULTURAL

Patient do not believe in superstitious belief

RELIGION

Patient is an Roman Catholic, and has a strong faith


in his religion.

ECONOMIC

Patients financial support came from his children


Economically stable and seems to have no financial
difficulties
High school graduate

EDUCATIONAL

MEDICAL

Members of the family had adequate education


such that most of the problems encountered were
settled satisfactorily

Not burdened by inadequate educational


attainment
The family has a good health seeking behavior.
Patient utilizes hospital and health center within his
community

PATHOLOGY

Trajectory of Illness
Stage IV: Early adjustment to outcome

Family in Functional
Equilibrium

ADAPTATION
Caregivers
knowledgeable of
the diagnosis and
caring for the
patient

Smilksteins
Cycle of
Family
Function

STRESSFUL LIFE EVENTS

The illness of Leg pain

FAMILY NOT IN EQUILIBRIUM

RESOURCES

Financial support from


Son
Medical resources:
Jonelta check-up

Family income barely enough to


support everyday expenses and
patients treatments and
medications

Caregivers with little knowledge on


the illness of A.M

PERSONAL AND SOCIAL HISTORY


(-) Previous smoker:
(-) Previous alcoholic drinker

REVIEW OF SYSTEMS
NEUROLOGIC

No headache, no seizures

SKIN

No jaundice; senile

HEENT

No headache, no vertigo, no ear


pain,
no nasal obstruction

CARDIOVASCULAR

No orthopnea, no palpitation

GASTROINTESTINAL

No constipation, no diarrhea

URINARY

No dysuria, no hematuria

GENITALS

No discharge, no redness

EXTREMITIES

No edema, no limitation of
movement

HEMATOLOGIC

No bleeding tendencies

PHYSICAL EXAMINATION
GENERAL SURVEY
Awake, conscious, coherent, not in cardiovascular distress
VITAL SIGNS
BP: 140 / 70 mmHg
PR: 81 bpm
RR: 20 cpm
Temp: 36.70C
O2 Sat: 99%
SKIN
warm to touch, senile skin
turgor,
no active dermatoses
HEENT
Anicteric sclerae,
pink palpebral conjunctiva,
no nasoaural discharge, no
tonsillopharyngeal congestion,
no cervicolymphadenopathy,
(-) dry lips

CHEST / LUNGS
Symmetrical chest expansion,
clear breath sounds
(-) retractions
HEART
Adynamic precordium,
normal rate, regular rhythm,
no murmur
ABDOMEN
Flat, normoactive bowel
sounds, soft, non-tender,
(-) hepatomegaly
EXTREMITIES
Grossly normal extremities,
full and equal pulses, (-)
edema,
(-) cyanosis

NEUROLOGIC EXAMINATION
CEREBRUM

Oriented to person, place and


time

MOTOR

CEREBELLUM No nystagmus
CN I

Can smell

CN II

2-3mm, equally reactive to light

CN III,IV, VI

Intact extraocular muscles

CN V

Can clench teeth

CN VII

No facial asymmetry

CN VIII

Able to hear

CN IX, X

Uvula at midlline, able to


swallow

CN XI

Can shrug shoulders

CN XII

Tongue at midline

5/5

5/5

5/5

5/5

100
SENSORY %
100
%

DTR

100%
100%

++

++

++

++

FAMILY WELLNESS
PLAN

Mercedita, 79/F
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
Breast exam: self breast a& MD exam regularly
ANNUAL: papsmear ,DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash

Mercedita, 79/F
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: DT

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments,
compliance to maintenance medication
ILL HEALTH: consultation, family participation
in health care, education management
including follow up and referral

Juanito, 78/M
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
ANNUAL: DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash

Juanito, 79/F
Screening
Health behavior: smoking, alcohol, caffeine,
occupational hazard, accident
Immunization: DT

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments,
compliance to maintenance medication
ILL HEALTH: consultation, family participation
in health care, education management
including follow up and referral

John, 43/M
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
Family planning
ANNUAL: DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash

John 43/M
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments,
compliance to maintenance medication
ILL HEALTH: consultation, family participation
in health care, education management
including follow up and referral

Annaliza, 42/F
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
Breast exam: self breast a& MD exam regularly
ANNUAL: papsmear ,DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Family planning

Annaliza, 42/F
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments,
compliance to maintenance medication
ILL HEALTH: consultation, family participation
in health care, education management
including follow up and referral

Nathaniel, 23/F
Screening

BP: annual
Annual cholesterol, fbs
Visual acuity: annual
Hearing: depend on work exposure
ANNUAL: FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash

Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments
ILL HEALTH: consultation, family
participation in health care, education
management including follow up and
referral

Patrick, 21/M
Screening

BP: annual
Annual cholesterol, fbs
Visual acuity: annual
Hearing: depend on work exposure
ANNUAL: FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash

Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments
ILL HEALTH: consultation, family
participation in health care, education
management including follow up and
referral

Kabella, 19/F
Screening

BP: annual
Annual cholesterol, fbs
Visual acuity: annual
Hearing: depend on work exposure
ANNUAL: FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash

Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal

Developmental monitoring

PHYSICAL: weight (obesity)


MENTAL: prime MD
SOCIAL: marital relationship, family
relationship
MEDICATION: OTC for common ailments
ILL HEALTH: consultation, family
participation in health care, education
management including follow up and
referral

Final Diagnosis
Type of family: Unilaterally extended
Family APGAR: Highly functional family
Family SCREEM:
Family has adequate resources to cope with
crisis
Stage of Family Life Cycle: Family in later years
Trajectory of Illness:
Stage IV Early adjustment to outcome
Smilksteins cycle of family function:
Family in equilibrium

Final Diagnosis
Biomedical Diagnosis:

Osteoarthritis, HPN II Controlled, DM


type 2

Stage IV: Early adjustment to outcome

Das könnte Ihnen auch gefallen