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Barely a kilometer from the finish line. by: Angustia , Ayes, Chan, Co, Garcia, Macapinlac , Tumibay , Vega 23 July 2010. A Family Case Presentation. Outline. Characteristics of the New Model of Practice for Family Medicine The Family Case Presentation.

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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