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CASE PRESENTATION. BAUTISTA, BERNARDINO, PALARCA, RAMOS, ZABALLA. General Information. V.O. 73 year old female November 4, 1941 Widowed Filipino Roman Catholic Gawad Kalinga, Payatas. Chief Complaint: Weakness. Review of Systems. Review of Systems. Review of Systems.

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case presentation

CASE PRESENTATION

BAUTISTA, BERNARDINO, PALARCA, RAMOS, ZABALLA

general information
General Information
  • V.O.
  • 73 year old female
  • November 4, 1941
  • Widowed
  • Filipino
  • Roman Catholic
  • Gawad Kalinga, Payatas
physical examination1
Physical Examination

Musculoskeletal Exam and Reflexes: good muscle tone (5/5 on all extremities)

Neurologic Examination:

Cranial Nerves I, II: not assessed

III: intact extraocular muscle

IV, V, VI: not assessed

VII: no facial asymmetry

VIII: intact gross hearing

IX, X, XI: not assessed

XII: tongue midline

Motor: 5/5 on all extremities

Sensory: no sensory deficits

initial impression
Initial Impression

Hypotension probably secondary to Anti-Hypertensive Medication Overdose

Congestive Heart Failure NYHA II

Hypertension Stage II, controlled

slide31

ORDINARIO FAMILY

February 21, 2014

73

5

44

42

22

23

12

10

7

family with adolescents
Family with Adolescents
  • Young children are getting older and turning into more independent individuals
issues
Issues
  • Shifting of parent-child relationships to permit adolescent to move in and out of the system
  • Identity, autonomy and sexuality issues
  • Refocus on midlife, marital, and career issues
  • Beginning shift towards concern for the older generation
in phase or out of phase
In phase or out of phase?
  • Out of phase hence the family has higher risk for physical and emotional symptoms
  • Ate Corra and her husband Danilo who both are head of their household have very little time to focus on themselves
    • Instead are focused on taking care of the other members of their household
  • Note: Burden of taking care of the kids and the grandparents.
developmental challenges
Developmental Challenges
  • Shifting of parent-child relationships
    • Be able to balance giving independence to adolescents at the same time acknowledge responsibility roles
  • Changes in the caregiver role of the family
    • The primary caregiver burden will be upon the parents
how it relates to the patient
How it relates to the patient
  • Important to acknowledge caregiver fatigue
    • Note that prognosis of the patient’s disease and the degree of care needed by the patient
  • Expenditures in terms for her health care vs. the adolescents eventual need to go into college.
slide39

23

73

22

44

10

12

42

7

family intervention tools
Family Intervention Tools

Home Visits, Family Meetings and Episodic Consults

pre home visit
Pre Home Visit
  • Date of Visits: February 18,20,24
  • Purpose of Visit:
    • Information gathering
    • Caregiving check and evaluation
    • Information gathering
    • More extensive evaluation
  • Why the patient needs a home visit?
    • Poor health seeking behaviour and health practices
pre home visit1
Pre Home Visit
  • Tools to utilize during visit
    • Family Genogram
    • Family Map
    • APGAR
    • SCREEM
  • Educational information to be discussed with the patient and family
    • Diet modification
    • Compliance to medications
    • Complications of current chronic illnesses
    • Prevention of complications
home visit outcome
Home Visit Outcome
  • Biomedical Status
    • Current health status:
      • Hypertension Stage II, controlled
      • Congestive Heart Failure NYHA II
    • Medications
      • Losartan 50 mg OD, Amlodipine 10 mg OD, Simvastatin 20 mg ODHS
    • Emotional Mental Status
      • Depressed and with low self esteem
    • Functional Assessment
      • Able to take care of self and usually sits outside the house. No role in daily livelihood. No hobbies.
home visit outcome1
Home Visit Outcome
  • Contextual Environment
    • Physical Setup
      • Density: 8 pax in a 2 bedroom GK unit
      • Ventilation: Fair
      • Sanitation & Pest Control: Fair
      • Garbage Disposal: Twice a week
      • Water & Food Handling: Fair
      • General hygiene and housekeeping: Fair
      • Exposure to hazardous substances: (+) smoke from burning garbage
home visit outcome2
Home Visit Outcome
  • Contextual Environment
    • Psychosocial Setup
      • Caregiving and safety: Fair
      • Provision for privacy: Fair
      • Social environment: Good
      • Accessibility to healthcare services: Good
home visit outcome3
Home Visit Outcome
  • Activities done with patient and family
    • Inquiry on nutritional status of the patient as well as her compliance with her medications.
    • Determined presence of dysfunctional behavior or attitude towards Lola Veron that could affect compliance to the treatment plan.
    • Assessment of relational status of the children with Lola Veron and how they care for her
    • Probed the family dynamics as well as the misconceptions of the family regarding Lola Veron’s condition.
    • Family education as well as helping members to empathize with the index patient
home visit outcome4
Home Visit Outcome
  • Recommendations
    • Biomedical
      • Daily BP monitoring and auscultation c/o health hub
      • Strengthen compliance with diet plan and fluid restriction
      • Regular blood exams: LFTs, renal function tests, cholesterol, FBS
    • Contextual
      • One family member to be in charge in checking compliance of Lola Veron
      • Family to emphatize with what Lola Veron is going through
      • Identify possible hobbies or livelihood projects that can engage Lola Veron and use her time more meaningfully
pre family meeting
Pre Family Meeting
  • Date
    • February 20, 2014
  • Agenda of the Meeting
    • Information gathering on family dynamics
    • Discussion of treatment plan and lifestyle modification
  • Intended Attendees
    • Patient’s Children and grandchildren + Interns in charge
  • Hypothesized Problem/Issue
    • Difficulty of complying with medications and lifestyle changes
    • Assignment of caregiver roles
    • Misconceptions about Lola Veron’s disease
  • Goals and Targets
    • Assign point person in charge of making sure that Lola Veron is complying with medications and diet plan
    • Correct misperceptions and educate family about the patient’s condition
    • Brainstorm on other possible activities that may engage Lola Veron to be more functional
family meeting outcome
Family Meeting Outcome
  • Attendees
    • Veron, Corra, Geraldine, Danilo + Interns in charge
  • Problems/Issues & Priorities
    • Misperceptions on disease
    • Misunderstandings in the family due to Lola Veron’s attitude and refusal to accept advice from anyone in the family
    • Compliance to medications and diet modification
    • Lola Veron’s decreased self esteem – she feels that her grandchildren gives her little respect
  • Family’s Concerns
    • Lola Veron’s attitude
    • Caregiver role
family meeting outcome1
Family Meeting Outcome
  • Identified Challenges
    • Instilling empathy on other family members regarding the patient’s condition
    • Managing the patient’s changes in behavior and lack of self esteem
    • Caregiver fatigue
  • Common Shared Goals and Strategies
    • To achieve better lifestyle and compliance for Lola Veron
    • To reestablish harmony in the family amid the crisis
  • Action Plan
    • Let everyone in the family understand what the patient has been going through
    • Help her cope and adjust with changes
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