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COMMUNITY GRAND

ROUNDS
Group 2

Suller, Armida
Sunga, Mary Anne
Suntay, Ma. Lourdes
Sy, Jennifer Paula
Tabuena, Gertzie Dara
Tacujan, Karina Michaela
Tad-y, Mia Marie
Talusan, Patrick Jason
CLINICAL ASSESSMENT
Clinical Assessment
E.B., 11 month old male
Area I, Lot 37, Block 52, Brgy. Sto. Niño, Sapang
Palay, San del Monte City, Bulacan

Chief Complaint: Yellowish nasal discharge

Informant: Mother
Reliability: 85%
History of Present Illness
• watery nasal discharge
14 days PTC
• cough productive of whitish sputum

• persistence of symptoms + fever (38ºC)


13 days PTC
• Paracetamol 1 mL q6h  lysis of fever

10 days PTC • Cough productive of yellowish sputum

• decrease in appetite
7 days PTC
• A> Viral bronchitis
• P> Salbutamol 2 mg/5 mL, 2.5
mL q6h for 7 days; Increase
fluid intake  cough improved
• yellowish nasal discharge
Consultation
Review of Systems
General survey Gastrointestinal
– active – (-) vomiting
– (-) weight loss – (-) change in bowel movements
– (-) food intolerance
Cutaneous Genitourinary
– (-) rash – light yellow urine
– (-) pigmentation – (-) discharge
– (-) edema of the hands and feet
HEENT
– (-) excessive lacrimation, Nervous
nasal or aural discharge – (-) vomiting
– (-) epistaxis – (-) convulsions
– (-) weakness or paralysis
Cardiovascular
Musculoskeletal
– (+) fainting spells – (-) swelling
– (-) limping
Respiratory
– (-) difficulty of breathing Hematopoietic
– (-) pallor
– (-) easy bruisability
Past Personal History

Gestational History
– 21 y/o
– G2P1 (1-1-0-1)
– healthy
– good nutrition
– no infections
– no intake of drugs
– 9 months gestation
Past Personal History
Birth History
– term
– NSD
– physician attended the birth (Ospital ng
Maynila
– birthweight 7.5 lbs
Past Personal History
Neonatal History
– spontaneous respiration, no required
resuscitation
– acyanotic
– no pallor or jaundice
– no convulsions
– no hemorrhage or feeding difficulties
Past Personal History
Feeding History
– Breastfed for 1 month
– Age weaned: 1 month; reason: due to
galactocoele
– Formula: Bona
– Medications: multivitamins
– Food intake: (+) solid foods at 6 months
– fed every (hours)?
– consumes (bottles of milk in 24 hours)?
Past Personal History
Growth and Development
- Talked: 6 mos (“mama” and “papa”)
11 mos (other than “mama” and “papa”)
- Sat alone: 9 mos
- Stood alone: 10 mos
Past Personal History
Immunizations
– BCG (1 mo)
– DPT, OPV (2,3,and 4 mos)
– Measles (9 mos)

• Where was it given? (health center, hospital)?


Past Personal History
Past Illnesses
– Dx: pneumonia at 8 mos
Rx: Cotrimoxazole 200 mg/40 mg/5 mL syrup,
given 2.5 mL q12h for 5 days
– no operations
– no asthma or known drug sensitivities
– no injuries
Family History
• Parents:
– Father: Jojo, 25 y/o, no permanent occupation,
healthy
– Mother: Adeline, 22 y/o, housewife, healthy

• Siblings:
– Older brother died at 2 days old

• Familial illness or anomalies:


– (+) Cardiovascular disease - grandmother
– (-) Tuberculosis, diabetes mellitus, syphilis,
cancer, epilepsy, rheumatic fever, allergy,
hereditary hematological disorders, mental
retardation, congenital defects, etc.
Socioeconomic and
Environmental History
Living Circumstances
– Two-storey house, made of concrete, space
enough for six people, well-ventilated.
Economic
– Family’s source of income: father (construction
worker in Manila)
Environmental
– (+) exposure to cigarette smoke (mother)
Physical Examination
General: conscious, not in distress, well malnourished,
good hydration, and well-developed

Vital signs and Anthropometrics:


– Height: 77 cm (p75)
– Weight: 10 kg (p50)
– HC: 47 cm (p75)
– CC: 48 cm
– AC: 45 cm
– RR: 35 bpm
– PR: 116 bpm
– T: 36oC
Physical Examination

• WFA: actual wt/wt at p50 x 100 =


(10kg/10 kg) x 100 = 100 %  normal

• HFA: actual ht/ ht at p50 x 100 =


(77 cm/ 74 cm) x 100 = 104 %  normal

• WFH: actual wt/ wt at ht p50 x 100 =


(10 kg/10.6 g) x 100 = 94.33 %  normal
Physical Examination

Skin
– fair, good turgor, no rashes, no scars, no edema

Head
– equal distribution of hair, normocephalic and atraumatic,
anterior and posterior fontanels are closed, no abnormal
swelling or depressions, no overlapping sutures

Eyes
– pink palpebral conjunctiva, anicteric sclerae, pupils ERTL,
no opacities or abnormal discharge
Physical Examination
Ears
– no abnormal discharge, no inflammation or foreign
bodies

Nose
– patent nares, no flaring of alar nasi, midline septum

Oral Cavity
– pink, moist buccal mucosa, (+) upper and lower central
incisors, no lesion or hemorrhages, non-hyperemic
posterior pharyngeal walls, tonsils not enlarged
Physical Examination
Neck
– no venous engorgement, no rigidity, no thyroid enlargement, no
abnormal masses, no palpable lymph nodes
Thorax
– symmetric chest expansion, no retractions, head circumference
> chest circumference
Lungs
– no lagging, clear breath sounds
Heart
– adynamic precordium, AB 4th left ICS MCL, no lifts heaves or
thrills, base: S2>S1, apex: S1>S2, no murmurs
Abdomen
– globular, umbilicus midline, no visible veins or abnormal
pulsations, normoactive bowel sounds, nontender, no masses,
tympanitic
Physical Examination
Extremities
– pulses regular, full and equal

Neurologic Examination
– General: alert, normal facial movements
– Motor: symmetry of arm and leg movements, normal muscle
bulk, no atrophy, adequate muscle strength for age, good grasp
of objects
– Cerebellar: no tremors and not hypotonic
– Developmental reflexes: (+) palmar and plantar grasp reflex, (-)
Moro, rooting and tonic neck reflex
– Primitive postural reflexes: (-) placing and stepping reflex, (+)
supporting reaction, (+) Landau reflex
DIFFERENTIAL DIAGNOSES
ACUTE BRONCHITIS
• inflammation of the trachea, bronchi, and
bronchioles
• 90% are viral in origin
• Prevalent throughout the world
• One of the top 5 reasons for childhood
physician visits
• Peak age: <2 years; 9-15 years old
ACUTE BRONCHITIS

• Cough, watery nasal discharge, fever,


sore throat
• Crackles, rhonchi or wheezing
• Self-limited (Resolves in 10-14 days)
– Supportive (hydration, oxygen, anti-
pyretics, avoidance of smoke)
– Bronchodilators, antitussives, expectorant
BRONCHIOLITIS
• Acute infectious disease of the lower
respiratory tract
• Primarily in young infants, most often in
those aged 2-24 months.
• Due to a viral infection of the small
airways (bronchioles)
• MOST COMMON pathogen: RSV
BRONCHIOLITIS
• MOST COMMON PHYSICAL SIGN:
tachypnea
• Other signs and symptoms: cough, low-
grade fever, rhinorrhea, wheezing, signs
of respiratory distress
• Treatment: Supportive
PHARYNGITIS
• An inflammatory process of the oropharynx,
primarily caused by infections
• Streptococcal pharyngitis can affect persons
of all ages,
• Peak incidence in children: 5-15 years
• Unusual in children younger than 2 years
• Low-grade fever, clear rhinitis, irritability, and
anorexia
• Erythema & inflammation of uvula and
pharynx
• Treatment: Penicillin for 10 days
Impression

Upper Respiratory Tract Infection


t/c Acute Bronchitis
discussion
• Spectrum of URIs
- rhinitis
- rhinosinusitis – “common cold”
- nasopharyngitis
- pharyngitis
- laryngitis
- laryngotracheatis
- tracheatis
discussion
Rhinosinusitis defined

“A group of disorders characterized by


inflammation of the nasal mucosa and
paranasal sinuses”
discussion
• Pathogenesis of URI
physical
Direct
Interaction
inhalation Invasion of
w/ Immune humoral
mucosa
defenses
Hand to
mouth/nose cellular
Incubation of
pathogen

Production of
symptoms
discussion
Predisposing Factors:
–Viral URI
– Allergic Rhinitis Ostia Patency

–GERD
– Immunologic Defects
– Ciliary dysfunction Mucociliary Clearance

– Cystic Fibrosis Quality of Secretion


discussion

-Viral URI
Inflammation of the sinus ostia

Stasis /poor ventilation

Absorption of O2

Negative pressure

Movement of bacteria and nasal contents into the sinus


discussion
• Signs and symptoms of common colds
• Sore or “scratchy throat”
• Nasal obstruction
• Rhinorrhea
• Cough
• Fever – influenza, RSV, adenovirus
• Swollen, erythematous nasal turbinates
Discussion
incidence
• school children may suffer 7 to 10 colds/yr
• 0.5% to 2% of viral URTIs are complicated
by bacterial infection
• 13,517 out-patient consults seen from
Jan. to June 2005
– ABRS consists of 140 cases (1.035%)
– 36% of all cases consulting for rhinitis
Discussion
Other risk factors for URIs
– Group settings and crowded places
– Travel
– Smoking and exposure to second-hand
smoke
– Immunocompromise
– Anatomic changes
– Carrier state
Discussion
ACUTE BRONCHITIS
Infectious agent

Tracheobronchial epithelium

Activation of inflammatory cells & release of


cytokines
Discussion
• Symptoms
– Fever
– Malaise
– Rhinitis
– Frequent dry hacking cough - 3-4 days after

– Purulent sputum
Discussion
• Physical Examination:
– Absent or low grade fever
– Upper respiratory signs
– Coarse breath sounds
– Coarse and fine crackles
– Scattered high pitched wheezing
Treatment
• No real treatment for rhinosinusitis
– Caused by rhinovirus (101 sero types)
• Symptomatic treatment
– Fluids, proper nutrition
– Fever: antipyretic (Paracetamol)
– Nasal Obstruction: nasal decongestants
(Xylometazoline HCl)
– Rhinorrhea: Antihistamines (Loratidine), Ipratropium
bromide
– Sore Throat: mild analgesics (acetaminophen)
– Cough: Antihistamines (Loratidine)
Treatment
• Acute viral bronchitis
– No real treatment
– Self- limited
– Shifts in position: facilitate pulmonary
drainage
– Bronchodilators: Salbutamol
Treatment
• cool mist vaporizer or humidifier
– help decrease bronchial irritation
• Cough suppressant
– dextromethorphan
– Risk suppuration and insipissated secretions
• Guaifenesin
– loosen secretions
FAMILY ASSESSMENT
FAMILY GENOGRAM

Rodolfo Lorena Charles Arlene

Bong,29 Jennifer,27 Carlo,25 Rinna,15 Jonathan,27 Charlene,26 Adeline,22

Allyna,6mos Natalene,6 Nathaniel,1yr &8mos

Eugene Carl,11mos
FAMILY PROFILE
FAMILY MEMBER AGE/SEX CIVIL RELATIONSHIP TO EDUCATIONAL OCCUPATION STAYING WITH
STATUS THE HEAD OF ATTAINMENT THE
THE FAMILY FAMILY?

Rodolfo 48/M M Breadwinner High School Caddy Yes


Asentista Graduate

Lorena 45/F M Partner of Rodolfo High School Housewife Yes


Asentista Graduate

Rinna Asentista 15/F S Daughter of Rodolfo College Student - Yes


and Tess

Allyna Marithea 6 mos/F S Daughter of Jennifer - - Yes


Abella and Bong

Carlo Asentista 25/M M Son of Rodolfo and High School Waiter Yes
Lorena Graduate

Adeline Balanay 22/F M Daughter-in-law of High School Housewife Yes


Rodolfo and Graduate
Lorena

Eugene Carl 11 mos/M S Grandson of Rodolfo - - Yes


Asentista and Lorena
FAMILY LIFELINE

• 2005 - Carlo and Adeline lived-in

• 2006 - Eugene Carl was born


- Eugene had pneumonia
FAMILY LIFE CYCLE

FAMILY WITH YOUNG CHILD


First Order Changes
• Meeting predictable and unexpected costs of
family life with a small child
• Sharing responsibilities
• Maintaining mutually satisfactory sexual
relationship and planning for future children
• Facing dilemmas and reworking philosophies
• Assuring a healthy environment for the child
FAMILY LIFE CYCLE
Second Order Changes
• Realignment of relationship with
extended family to include parenting and
grandparenting roles
• Creating and maintaining effective
communication system
• Cultivating full potentials of relationship
with relatives within the extended family
• Tapping resources, serving needs and
enjoying contracts outside the family
PROBLEMS ENCOUNTERED
Medical
• Eugene’s Upper Respiratory Tract
Infection
• Smoking habits of both Carlo and Adeline
PROBLEMS ENCOUNTERED
Emotional and Social
• Financial difficulties – Carlo is not earning
enough for his family
• “Not so good” relationship of Adeline with
her mother-in-law
• Frequent disagreements between Carlo
and Adeline
ECONOMIC PROFILE
MONTHLY ALLOCATION OF
INCOME
• Food 6% Monthly Allocation of Income
• Electricity 50%
Food
• Shelter 4%
Electricity
• Household items 5% 3%1% 6%
8% 2%2% Shelter
• Water 20% Household items
• Health 8% Water

• Recreation 1.5% 20% Health


49% Recreation
• Clothing 2% 5% 4% Clothing
• Savings 3% Savings
• Others 0.5% Others
ECONOMIC PROFILE
EARNING OCCUPATION INCOME PER OTHER
FAMILY MONTH SOURCES
MEMBER OF
INCOME

Rodolfo Caddy P10,000 Pigs (P1200


Asentista per pig)

Carlo Waiter P2,000 -


Asentista
LOCATION MAP
General Floor Plan:

Stairs
Bathroom
Living Room

Kitchen
Bedroom And Dining Area

Windows
Bed
Attic
ENVIRONMENTAL PROFILE
House Two storey, owned by grandfather
Type Mixed (concrete, wood and GI sheets)
Number of bedrooms 2 bedrooms, kitchen, living room, 1 bath
and toilet
Order and cleanliness Minimal clutter
Floor area Living room doubles as sleeping quarters
Flooring Tiles and wood
Ventilation 4 windows
Electric supply Meralco
Lighting Good
Lighting facilities Fluorescent lights
ENVIRONMENTAL PROFILE
Water NAWASA (local water district)
Drinking water Tap water
Toilet type Manual flush (buhos-type)
Refuse disposal Not segregated
Garbage collection Disposable diapers only every Mondays
Incineration
Drainage Open
Vermin/insects Mosquitoes, mice, cockroaches, no vermin
control used
Pets: 5 dogs, 12 puppies, 2 pigs and poultry
Neighborhood Located near a barangay health center, St.
Martin, school and public market
Accessibility Dirt road
ASSESSMENT
POSITIVE POINTS NEGATIVE POINTS

Accessible Road not cemented (dirt road)

Sufficient and clean water source Presence of stray dogs and cats

With electrical source No waste segregation

No vermin control
TOOLS OF ASSESSMENT

APGAR
SCREEM
APGAR:
Adeline

A Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa 1


aking pamilya sa oras ng problema
P Ako’y nasisiyahan sa paraang nakikipagtalakayan sa 2
akin ang aking pamilya tungkol sa aking problema
G Ako’y nasisiyahan at ang aking pamilya ay tinatanggap 2
at sinusuportahan ang akong nais na gawin patungo sa
mga bagong landas para sa aking ikauunlad
A Ako’y nasisiyahan sa paraang ipinadadama ng aking 1
pamilya ng aking pamilya ang kanilang pagmamahal at
nauunawaan ang aking damdamin katulad ng galit,
lungkot, at pag-ibig
R Ako‘y nasisiyahan dahil ang aking pamilya at ako ay 1
nagkakaroon ng panahon para sa isa’t isa

TOTAL 7
APGAR:
1. Sino-sino ang mga nakatira sa inyong tirahan? Ano
ang iyong relasyon?
- Sa mga manugang kadalasan ay pinanasyal na
tulong.
a. In the future, what is the family’s primary goal?
- Their primary goal is to have all their kids finish
school and have a good, stable job.
b. Do all the members work together towards these
goals/desires? How? If not, what seems to be the
hindrance for working together?
- Yes, usually by communicating openly to each
other.
c. Is there any history of alcoholism, gambling, drug
abuse/dependency, domestic violence? Has something
been done to address this problem?
- Yes, specifically alcohol and drug use. In the past,
both Carlo and Adeline used Marijuana and shabu but
was not addicted to it. Carlo is an occasional drinker of
alcohol.
d. To what organization does the family belong to?
- El Shaddai
SCREEM:
Parameter Strength Weaknesses

Social -Open communication


-Slightly supportive
- No rivalries

Cultural - Absence of beliefs/practices


that are unacceptable in our
culture
Religion - Religion of the family:
Roman Catholic
-Joined El Shaddai
- Strong Relationship with
God
Education -Both parents are High -Level of education hinders the
School graduates progress of the family

Economic - Good allocation of - most of the time borrows money


funds from neighbors
Inspite that sometimes
there is lack of
money.
Medical - compliant
COMMUNITY ASSESSMENT
COMMUNITY ASSESSMENT
Positive points

• There are no piles of garbage in the area.


• The community is closely knit. They look
after each other’s welfare.
COMMUNITY ASSESSMENT
Negative points

• The pathways leading to their houses are


dangerously steep, and can become
slippery and muddy during the rainy
season.
• The community uses open drainage
system.