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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 examination abdomen
Physical Examination: Abdomen


Physical examination skin and extremities
Physical Examination: Skin and Extremities


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




ORDINARIO FAMILY

February 21, 2014

73

5

44

42

22

23

12

10

7


Family structure family life cycle
FAMILY STRUCTURE FAMILY LIFE CYCLE


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.



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





Episodic consults daily bp monitoring and auscultation
Episodic ConsultsDaily BP Monitoring and Auscultation




Ate corra 42
Ate Corra, 42


Danilo 44
Danilo, 44


Lizel geraldine 22 23
Lizel & Geraldine, 22 & 23



Reymer john hans 10 7
Reymer John & Hans, 10 & 7


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