HOSPICE CARE

UPDATES
September 8-12, 2014

BALANDRA ● BARON ● BEATRIZ ● BELLO

 1) HUERVANA, CELESTE

• 53 years old
• Female
• Married
• Brgy. Ingore,
La Paz,
Iloilo City
 Vital Signs:
• BP – 110/80 mmHg
• CR – 70-80s bpm
• RR – 20s cpm
• Temp – 36.9 C
• O2 Sat – 98%
 Chief Complaint:

S/P Cerebrovascular Disease with Left

Sided Weakness as residual

Pain on lower back and left hip;

tingling sensation on left lower extremity
secondary to fall
 Latest PE
• Awake, conscious, coherent, conversant,
comfortably lying on bed, coherent, cooperative,
not in cardiopulmonary distress

• Anicteric sclerae, pinkish conjunctivae, pupils are

equally round, reactive to light and
accommodation, moist lips and buccal mucosa

• No cervical lymphadenopathies, no neck vein

engorgement, no slurring of speech
PE cont’d…
• Symmetrical chest expansion with clear breath
sounds, no retractions, no wheezing, no crackles

• Adynamic precordium with PMI at 5th ICS left

midclavicular line, normal cardiac rate, regular in
rhythm, no murmur

• Soft, flabby, non-tender abdomen

• No urinary and bowel changes
• No new neurologic deficits
PE cont’d…
• Fair posture, slightly kyphotic
• No lesions, bruises, malformations noted at the
back
• Pain/tenderness on palpation of lower back
muscles
• Pain on left hip/acetabulofemoral joint upon
internally and externally rotating the left leg
• Tingling sensation on left lower extremity,
aggravated by ROM exercises
• Foot drop, left
• CRT < 2 sec
PE con’td…
Motors Sensory
R L R L

5/5 0/5 100% 50%

5/5 2/5 100% 50%

 PE con’td…
Cranial Nerves
I - able to smell
II - able to see, PERRLA
III, IV, VI - intact EOM
V - intact V1, V2, V3, 50% sensation only at L side
VII - intact muscles of facial expression, slight weakness, L
VIII - able to hear
IX, X - able to swallow
XI - able to turn head from side to side
-able to shrug shoulders
XII - able to protrude tongue, no fasciculations
 Plans
• Continue maintenance medications:
– Amlodipine 10mg/tab, 1 tab OD
– Losartan 100 mg/tab, 1 tab OD
– Vitamin B complex Tablet, 1 tab OD
– Fish Oil Capsule, 1 capsule OD
 Plans
• Continue daily ROM exercises
• Physical rehabilitation twice weekly (Sat and
Sun) or as tolerated
• Low salt, low fat, high fiber diet
• Daily monitoring BP and record
• Foot drop physiotherapy:
– Foot board use
– Bandaging
2) SUMAGAYSAY, ROSA

• 68 years old
• Female
• Married
• Brgy. Ingore,
La Paz, Iloilo City
 Vital Signs
• BP – 140/90 mmHg
• CR – 90-100s bpm
• RR – 15-20s cpm
• Temp – 36.5C
• O2 Sat – 98%
 Chief Complaint:
S/P Cerebrovascular Disease;
Diabetes Mellitus II; Hypertension Stage II
Pterygium, OU
 Latest PE
• General Survey:
– Awake, alert, ambulatory, coherent, cooperative,
slightly irritable, not in cardiopulmonary distress
• Anicteric sclerae, pinkish conjunctivae, pupils equally
round, reactive to light and accomodation
• Pterygium on both eyes; moist lips and buccal mucosa
• No cervical lymphadenopathies, no neck vein
engorgement.
PE cont’d…
• Symmetrical chest expansion with clear breath
sounds, no retractions, no wheezing, no crackles

• Adynamic precordium with PMI at 5th ICS left

midclavicular line, tachycardic, regular in rhythm,
no murmur

• Soft, flabby, non-tender abdomen

• Grossly normal extremities, good muscle tone,

CRT <2s, good skin turgor
PE cont’d…
Cranial Nerves
I - able to smell
II - Visual Acuity: counting fingers at 1 ft distance,OD;
counting fingers at 3 ft distance, OS; PERRLA
III, IV, VI - intact EOM
V - intact V1, V2, V3
VII - intact muscles of facial
expression
VIII - able to hear
IX, X - able to swallow
XI - able to turn head from side to side, able to shrug
shoulders
XII- able to protrude tongue, no fasciculations
PE cont’d…
Motors Sensory
R L R L

5/5 5/5 100% 100%

5/5 5/5 100% 100%

 Plans
• Continue maintenance medications:
– Losartan 100 mg/tab, 1 tab OD
– Metformin 500 mg/tab
– Vitamin B complex Tablet, 1 tab OD
• Daily BP monitoring and record
• Low salt, low fat, high fiber diet
• Avoid processed foods, biscuits and bread
 Plans
• Monitoring blood sugar
– Fasting Blood Sugar Test (September)
• Exercise regularly
• Stress/anger management
• Referred to Department of Ophthalmology at
Western Visayas Medical Center for surgical
management of pterygium
 3) DELA CRUZ, JELIANNE

• 5 years old
• Female
• Child
• Project 7,
Brgy. Sooc, Arevalo
Iloilo City
 Chief Complaint:
Upper Respiratory Infection - Resolved
 Vital Signs
• BP – Full pulses
• CR – 90s bpm
• RR – 20-24 cpm
• Temp – 36.4C
• O2 Sat – 98%
 Latest PE
• General Survey
– Awake, ambulatory, coherent, cooperative, non-
irritable, well-groomed, not in cardiopulmonary
distress
• Anicteric sclerae, pinkish conjunctivae, PERRLA, no
nasal discharges, moist lips and buccal mucosa, no
ear discharges, no neck vein engorgement, no
palpable cervical lymph nodes
PE cont’d…
• Symmetrical chest expansion with clear breath
sounds, no retractions, no wheezing, no
crackles, no use of accessory muscles
• Adynamic precordium with PMI at 5th ICS left
midclavicular line, regular in rhythm, no murmur
• Slightly protuberant, soft, non-distended, non-
tender abdomen, normoactive bowel sounds
• Grossly normal extremities, good muscle tone,
CRT <2s, good skin turgor
• No neurosensory and motor deficits
PE cont’d…

• No clubbing noted
 Plans
• Continue Multivitamins 1 tsp OD
• Reinforce health education on sanitation and
hygiene, and proper nutrition.
• Health education(proper hand washing,
wearing slippers at all time)
• Maintain good school performances at school
• Counseling of grandmother regarding
Jelianne’s status on adoption.
Plans

• Health
education on
environmental
sanitation
 Plans
• Updates from DSWD Arevalo
• Coordinated with DSWD Jaro and found out that:
 Father was confirmed to reside at Dungon A Jaro, Iloilo City
 Currently works as a Trisikad driver
 Grandmother works as a laundry woman in one kagawad in
Dungon A who happened to know the father of Gelianne
 Several meetings were held in the barangay and father was
present at all the meetings held
 Father is aware of his responsibilities but seemingly not to care
 Father was confirmed to be living with his 4th ‘wife’ from Lanit
Jaro Iloilo and now having a family (no. of children not
confirmed)
 Father occasionally gives his children 10 or 50 pesos as support
 Plans
• Statement of grandmother about
institutionalization
Masarangan ko pa naman, kung hindi na gd eh
ihatag ko sila sa DSDW.
 Plans
• Support
DSWD – 15 kg rice (once)
Religious group – not yet given
Studying of 2 kids – sponsored by a pastor
• Income
Laundry services every Saturday
Tito of the children (salt business)
 Plans
• Other updates
 Eldest sibling is not in favor of institutionalization
 If somebody is willing is adopt Gelianne, maybe
they would agree to adopt them 4
 She confirmed that she sometimes go to his
father to ask for money for rice but he would only
give her max of P50
 She confirmed that her father is re-married on his
4th wife and now has another family but is
unaware of how many children they now have
 Plans
• Other problems as of the moment:
Mother’s location still not confirmed
Gelianne’s birthday is not known hence they
have difficulty in processing papers
Lack of financial support
Health condition of the other children in the
family (2nd kid has bouts of cough)
4) PARREÑO, JULIUS

• 63 years old
• Male
• Married
• Veteran’s Village,
Duran,
Iloilo City
 Vital Signs:
• BP – 110/70 mmHg
• CR – 86 bpm
• RR – 18 cpm
• Temp – 36.2 C
• O2 Sat – 98%
Chief Complaint:

S/P Stroke;
Weakness on
Right Upper
Extremity
 Latest PE
• Awake, conscious, comfortably lying on bed,
speaks in little words, often uses non-verbal
actions to express self; cooperative, not in
cardiopulmonary distress

• Anicteric sclerae, pinkish conjunctivae, pupils are

equally round, reactive to light and
accommodation, moist lips and buccal mucosa
• No cervical lymphadenopathies, no neck vein
engorgement
PE cont’d…
• Symmetrical chest expansion with clear breath
sounds, no retractions, no wheezing, no crackles

• Adynamic precordium with PMI at 5th ICS left

midclavicular line, normal cardiac rate, regular in
rhythm, no murmur
• Soft, flabby, non-tender abdomen
• Muscle wasting present on lower extremities
and right arm and hand, muscle atrophy of right
hand, dislocated right shoulder
L Hand R Hand
R Shoulder L Shoulder
X-ray Result (R shoulder)
X-ray Result
(Right
shoulder)
PE con’td…
Cranial Nerves
I - able to smell
II - able to see, PERRLA
III, IV, VI - intact EOM
V - intact V1, V2, V3
VII - intact muscles of facial
expression, slight weakness at R side
VIII - able to hear
IX, X - able to swallow
XI - able to turn head from side to side, able
to shrug shoulders
XII - able to protrude tongue, no
fasciculations
PE con’td…

Motors Sensory
R L R L

2/5 5/5 100% 100%

3/5 5/5 100% 100%

 Plans
• Continue maintenance medications:
– Simvastatin 40mg 1/2 tab OD
– Metformin 500mg/tab 1 tab BID
– Aspirin 80mg/tab 1 tab OD
– Amlodipine 10mg/tab 1 tab OD

• Place right arm in sling as tolerated

 5) VALENZUELA, VICENTA

• 80 years old
• Female
• Married
• Dungon B,
Jaro, Iloilo City
Chief Complaint:
Skin Pressure Ulcers
 Vital Signs
• BP – 110/60
• CR – 80s bpm
• RR – 18 cpm
• Temp – 37.5C
• O2 Sat – 98%
 Latest PE
• General Survey
– Awake, sitting on comode, covered with blanket,
contractures at joints, extremities flexed, not in
cardiopulmonary distress
– NGT at left nostril, black residue inside NGT
(Vitamins)
– With attached Foley catheter, cloudy urine present
at urine bag
– Some ants crawling over patient
PE cont’d…

• Anicteric sclerae, pale conjunctivae, PERRLA,

dry lips, moist buccal mucosa, healing wound
at right ear
• No cervical lymphadenopathies
• Adynamic predordium, PMI at 6th ICS left
midclavicular line, no murmurs
PE cont’d…

• Symmetrical chest expansion, clear breath

sounds, no wheezing, no crackles
• Soft abdomen
• Rigid joints with beginning pressure sores at
medial aspect of knees, 0/5 muscle grading on
left side
PE cont’d…

• Bipedal pitting edema (Grade 1) on both feet

• Grade 3 pressure ulcers at both trochanteric
areas and left sacral area
• Ulcer at left trochanteric area with
seropurulent foul-smelling discharge
• Blisters at sacral area
 Plans
• Wound dressing all areas with ulcers
• Advise proper daily wound care dressing
• Repeat urinalysis
• Formulate dietary plan for patient
Plans cont’d…

• Continue medications:
– Daikin solution TID
– Solcoseryl cream TID after Daikin wash
– Simvastatin20mg, ½ tab OD(lunchtime)
– Aspirin 1tabOD(every other day by folk)
(lunchtime)
– Vitamin C (Doctri-cee)1 tab OD (AM)
– Herbal/Supplements(RestoreLyfandC24/7) 1tabOD
(AM)
Plans cont’d…

• Continue passive ROM exercises c/o folks

• Change position every 2 hours

 Plans
• Updates on Food
Same as the family’s food, but osteorized
3 feedings
Daughter not much concern/unaware
whether her mother is getting enough
nutrients
Food preparation from Manila was available
but she only tried it once, it was cumbersome
according to her
ELIMANAO, RODRIGO SR.

• 70 years old
• Male
• Married
• San Juan, Molo,
Iloilo City
 Chief Complaint:
Neck Mass at Right Mandibular Area
 History of Present Illness
• 3 months PTC, (+)pain on swallowing, (+)small
nodule on right submandibular area, no
consult was done

• (+)wt loss ~50%, (+)decrease in appetite

 History of Present Illness
• 3 weeks PTC, (+)increased difficulty in
swallowing solid food and water, (+)difficulty
to expectorate, (+)difficulty speaking, (+)2-3
pillow orthopnea

• ODC, persistence of symptoms thus consult

 Past medical history
• 2007 – stroke, (+)residual right sided
weakness which improved slightly after 6
months
• 2013 – stroke, no new neurologic deficit
• (+)hypertension – since 2007, clonidine
75mcg/tab as prn
• (-)DM, (-)BA, (-)FDA, (-)TB
• (+)Herbal use
 Family History
• (+)HTN
• (-)DM, (-)BA, (-)CA
 Personal and Social History
• Retired Layson employee
• Smokes 2 packs/day starting at 15 years old
and stopped at 45. ~60 pack-year smoker
• Occasional alcohol drinker
 Vital Signs
• BP: 170/80 mmHg
• CR: 57 bpm
• RR: 24 cpm
• T: 36.7oC
• O2 sat: 98%
 Physical Examination
• General survey:
– Awake, lying on bed, cooperative but having
difficulty speaking, not in CPD
• HEENT:
– Anicteric sclerae, pinkish conjunctivae, PERRLA
– (+) 6x6cm elevated mass at right lateral neck, firm,
tender, nodular
 Physical Examination
• Chest and lungs:
– No masses/lesions, Symmetrical chest expansion
– Diminished breath sounds bibasal
– (-)wheezing, (-)crackles
• Heart
– Adynamic precordium, PMI at 5th ICS left MCL
– (-)murmurs, Regular cardiac rhythm
 Physical Examination
• Abdomen
– (+)mass, soft, lobulated, tender at RUQ
– (+)pulsations at periumbilical area
– Hypoactive bowel sounds
– Bladder nondistended
• Extremities
– Grossly normal, No atrophy noted
 Cranial Nerves
• CN I – not assessed
• CN II – pupils equal, reactive to light and
accommodation
• CN III, IV and VI – intact EOMs
• CN V – facial sensation intact
• CN VII – (+) facial asymmetry
• CN VIII – able to hear and understand command
• CN IX, X – able to swallow (w/ pain)
• CN XI – able to stick out tongue, deviated to the left
• CN XII – able to shrug shoulders
 Motor and Sensory
Motor Sensory
R L R L

5/5 5/5 100% 100%

5/5 5/5 100% 100%

 Impression
• Right lateral neck mass
 Diagnostics
• Cytopathology report (FNAB of left lateral neck
mass) – Cytomorphologic findings consistent w/
actue inflammatory pattern w/ atypical cells
• Fecalysis – (+)trichuris 3ova/smear; (-)occult
blood
• CXR PA – senile pulmonary emphysematous
changes; atherosclerotic aorta; thoracolumbar
hypertrophic degenerative osteoarthropathy
 Diagnostics
• UTZ of neck – sonographic examination of the
right cervical area reveals a 12.0 x 10.5 x 8.2
cm (LxWxAP), thick-walled complex mass w/
central necrosis and internal echoes. There is
vascularity on Color flow study of the thick
wall/solid component
– Impression: Complex mass, right cervical area
• ECG – non specific ST-wave changes
 Working diagnosis
• Right lateral neck mass;
• s/p aspiration biopsy;
• s/p irrigation and drainage
 Medications Given
• Co-amoxiclav 12g IVTT Q8h
• Clindamycin 300mg/cap, 1 cap Q6h
• Tramadol 50mg/tab, 1 tab Q8h
 Discharge Plans
• Maintain on NGT feeding 1500kcal/day in 6
divided feedings
• Home meds:
– Clindamycin 600mg/cap, 1 cap 4x/day for 7 days
– Lactulose 30cc once a day at night, hold for
BM>2x/day
– Tramadol 50mg/tab, 1 tab 3x/day as needed for
pain
Thank you for
listening!!!