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A Family Case Presentation

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  1. Barely a kilometer from the finish line... by: Angustia, Ayes, Chan, Co, Garcia, Macapinlac, Tumibay, Vega 23 July 2010 A Family Case Presentation

  2. Outline • Characteristics of the New Model of Practice for Family Medicine • The Family Case Presentation

  3. I. Characteristics of the New Model of Practice for Family Medicine • A personal medical home for each patient • Patient-centered care • A team approach to care • Elimination of barriers to care • Advanced information systems, including integrated electronic health records (EHRs) • Redesigned, functional offices • Whole-person orientation • Care provided within a community context • Emphasis on quality and safety • Enhanced practice finances (through operating efficiencies and new revenue streams) • A commitment to provide family medicine's “basket of services”

  4. II. The Family CP • Introduction • Clinical History of the patient • Heat stroke • Family Assessment Tools • Results of Assessments • Impact of illness to the patient and the family • Family System Theories • Conclusion and Recommendations

  5. A. Introduction II. The Family CP

  6. Introduction • Purpose of the presentation • Why was this case chosen? • What points will the audience focus into? • Identifying data • Chief complaint • Patient’s most obvious concern • Concern of the main caretakers

  7. Purpose of the CP • Why was this case chosen? • A sudden situation • Timeliness • Family Medicine • PH significance

  8. Purpose of the CP • Purposes: • Re-evaluation/formulation of the problem • Development of a comprehensive treatment plan • Guidance on issues, impasses, sensitive events • Discussion of diagnostic features, therapeutic techniques or biopshycosocial dynamics

  9. Focus of the CP • Impact of illness to the patient and family • Coping mechanism • Family dynamics • Social resources

  10. Identifying Data • Remus Fuentes(R.F.) • 37 y/o, Male, Married with two young children • IT expert, HP employee, Metro Manila • No known co-morbidities

  11. Chief complaint (CC) • Loss of consciousness (LOC) • a concern of the family

  12. B. Clinical history of the patient II. The Family CP

  13. III. Clinical History of the Patient • Course of illness • History • PE • Diagnostics and Results • Diagnosis • Course in the ER, ICU

  14. Course of illness • History • PE • Diagnostics and Results • Diagnosis • Course in the ER, ICU

  15. Marathon • collapsed on 19.9km mark • taxied to Ospital ng Maynila • hyperthermic, and with seizures • given Paracetamol • intubated • family opted for transfer to Medical City

  16. Medical City • reintubated • worked up for metabolic, neurologic and cardiac causes • Impression after evaluation: Heat stroke -- treated accordingly • doctors informed wife about the condition, its possible consequences • consent for procedures

  17. Medical City • Patient initially stabilized • episodes of hypotension • BP of 50/30 despite being on maximum pressors • cardiac arrest • declared dead after 45 min of resuscitation

  18. C. Heat stroke II. The Family CP

  19. Heat Stroke • Definition • Epidemiology and Incidence • Pathophysiology • Differentials • Diagnostic work-ups • Management – pharma (include MOA if applicable) and non-pharma • Prognosis • Prevention • PH

  20. Heatstroke • Most severe and deadly heat-related illness • Definition: Body temp 41C assoc. w/ neurologic dysfunction • 2 types • Classic • Exertional heatstroke

  21. Epidemilogy and Incidence • Common in tropical countries  Philippines • Cases increase in hot and humid weather • Increase risk for people staying outdoors and dehydrated • No sex or race predilection • Higher risk for extremes of age

  22. Pathophysiology • Imbalance of heat gain and heat loss • Excessive heat  denatures proteins in body • HSP and inflammatory cascade  more damage to body

  23. Differentials • Amphetamine or cocaine toxicity • Myocardial infarction • Stroke • Delirium tremens

  24. Work-up • CBC • Cardiac markers • Urinalysis • Muscle function test (CK, lactate dehydrogenase) • ECG • CXR • CT scan

  25. Treatment • Medical EMERGENCY • THERAPEUTIC HYPOTHERMIA

  26. Treatment • Benzodiazipine • Hydration • Decrease temperature

  27. Prevention and PH • Preventable disease • EDUCATION = most important tool

  28. D. Family assessment tools II. The Family CP

  29. http://www.filairsoft.com/forum/showthread.php?t=91297

  30. Family Profile

  31. Family Genogram I ? 37 II 8 4 III

  32. Family Structure • Nuclear Family

  33. Family Life Cycle Stage • Family with young children • Parent team approach • Getting used to new roles • Formation of new alliances

  34. Other family members at-risk of the condition • Younger brother, Roy, who is also a runner • Allies in the management • Father, Rudy, who is the stronghold/rock of the family and who makes the major decisions • Mother • Brother

  35. Family Map I ? II 37 III 8 4

  36. Dynamics of the family • Alliances and conflicts that will compromise cooperation in patient care • Strong alliance with young wife

  37. Illness Typology/Trajectory

  38. Illness Typology • Acute Onset • Family could not create a meaning for the illness • No time to grieve • No course – acute onset • Misdiagnosis can lead to death

  39. Time line and phase of illness Crisis Chronic Terminal PHASES Diagnosis Death TIME LINE Initial adjustment period Chronic ‘long haul’ Mourning and Resolution of loss Pre-diagnosis w/ symptoms Pre-terminal

  40. Kubler Ross Stages of Grief

  41. Stages of Grief • Father • Anger – vents his anger and frustration with the event organizers through an internet blog. Seeks justice for the untimely death of his son. • Bargaining – appearing to be strong despite the situation • Mother • Denial - mother was still wishing that the patient would regain consciousness • Wife • Anger – was hysterical at the ER. Needed the support of her sister to calm her down • Denial – could not grasp the concept the state of being “critical”

  42. SCREEM

  43. SCREEM

  44. SCREEM

  45. Illness as crisis

  46. Four Areas of Assessment • Type of Illness • Flexibility and Openness of the family • Stage at which illness occurs • The role that the sick person plays

  47. Type of Illness • Acute Severe • May uncover hidden dysfunction between wife and the in-laws • The sudden onset of the illness brings greater stress to the family • Flexibility and Openness of the family • Lifeline • Ambulance ride • Ospital ng Maynila • Transfer to TMC-ER • TMC-ICU • Code 99 after 42 hours after collapse

  48. Coping mechanisms of family • Wife-hysterical, did not want to see husband suffering • Sister of the wife – support system for wife • Brother – in state of shock • Father – finger pointing • Mother – worried and hopeful • Stage at which illness occurs • Out-of-phase • Young, healthy male, at the prime of his life with a new family and no co-morbidities