Quirino Memorial Medical Center

Department of Family Medicine and Community Health

Family Case Report

September 2018

GROUP B
LABAN, Francis Dominic
LIBERATO, Aemil
LUSTESTICA, Kirk Lee
MARTINEZ, Angela Beatrice
MISADOR, Ma. Houreya Xeryl
MONASTERIO, Ma. Carol
 GENERAL OBJECTIVE

To determine health concerns of the family and

provide basic healthcare to the patient and members
of her family under the Department of Family Medicine
and Community Health (FMCH) of Quirino Memorial
Medical Center.
 SPECIFIC OBJECTIVES

• To assess the structure, function, and the

relationship of the patient with her family.
• To assess the economic status of the patient and
her family if it is sufficient for their family.
• To discuss the patient’s satisfaction and/or
dissatisfaction with family function
• To discuss the effect of the patient’s illness on her
day to day activity, work, and familial relationships
• To assess the availability of support system of the
patient and her extended family
• To create a feasible management / health plan for
the patient and her family.
CLINICAL CASE
 GENERAL DATA

• 62 year old
• Female
• Quezon City
CHIEF COMPLAINT

Cough
 December
2017

9 months prior to consult, patient suddenly experienced

difficulty of breathing after taking meals, associated
symptom includes, shortness of breath. No other
associated symptoms such as chest pain, chest
heaviness, loss of consciousness, fever, cough, colds
and vomiting. Patient tried to drink a glass of water but
afforded no relief. No medications taken, due to
persistence and severity patient prompted to seek
medical consult in our institution and subsequently
admitted as a case of Aspiration Pneumonia.
 Hospital stay
December 2017-
January 2018

-During the hospital stay, patient was intubated and

hooked to mechanical ventilator however patient self-
extubated thereafter. Other symptom she had includes
bilateral leg edema.

***signed a waiver (DNI or Do No Intubate and HAMA or Home Against Medical

Advise)
 January
2018

Patient was discharged from the hospital and

diagnosed as a case of AKI secondary to DECV; CHF
NYHA IV, Hypertension stage II.
First follow-up and 2D echo and incentive spirometry
was done.
 . . . During the interim

• Patient noted limitation in doing daily activities due to

shortness of breath even at rest
• She prefers to be seated most of time
• Prefers to lie on her right side when sleeping, with (+) 2-3
pillow orthopnea and (+) paroxysmal nocturnal dyspnea
• Patient was lost to follow-up and non-compliant with
prescribed medications
 August
.
2018

1 month prior to consult, patient suddenly experienced

shortness of breath, which was worse than what she usually
experiences. No other associated symptoms such as chest
pain, chest heaviness, loss of consciousness, cough and
colds. No medications taken, persistence prompted patient
to seek consult in our emergency room, subsequently placed
on a heplock and given with intravenous medication that
was unrecalled. Patient was sent home thereafter with
unrecalled medications.
 September
.
2018

3 days prior to consult, patient experienced non-productive

cough, with slight shortness of breath, no associated fever,
and colds. No medications taken and no consult was done.
Patient was then referred by the Brgy. Officer for further
evaluation and management.
 PAST MEDICAL HISTORY
• Unrecalled childhood immunizations and unrecalled
childhood illnesses
• No known drug or food allergies
• (-) surgery
• (-) Asthma
• (-) Allergy to food and drugs
• (+) HTN—(Highest BP 200/ unrecalled diastolic; UBP: 140/90)
with maintenance of the following medications but patient is
non-compliant:
o Atorvastatin 40mg/tab 1 tab ODHS
o Clopidogrel 75mg/tab 1 tab OD
o Amlodipine 10mg/tab 2 tabs OD
o Losartan 50mg/tab BID
 FAMILY HISTORY

• (+) Hypertension, maternal

• (-) PTB
• (-) CVD
• (-) Diabetes Mellitus
• (-) Asthma
• (-) Cancer
 PERSONAL AND SOCIAL HISTORY
• Elementary graduate
• Previous heavy smoker with 192 pack years (4 packs per day –15
years old to December 2017)
• Chronic alcoholic beverage drinker – 1-3 bottles gin almost
everyday starting age 15 years old up to December 2017
Alcohol Use Disorder Identification Test Concise (AUDIT-C) score of 9----Likely heavy/hazardous
drinking

• Denies use of illicit drugs

• She prefers to eat vegetables, fried fish, shrimp paste
• She used to drink 2 cups of coffee a day  ½ cup of coffee a day
• No regular exercise
• Mini sari-sari store owner
• housewife
• 3 floors semi-concrete house, not well lit, not well-ventilated
• Pets: dogs that stays inside their house also with multiple pile of
sacks of wood coils for repacking.
 OB-GYNE HISTORY

M – 12 years old
I – 28-30 days
D – 3 days
A – 3-5 “pasador” moderately soaked
S – None
Menopause - 52 years old

OB SCORE – G8 P8 (8007)
 REVIEW OF SYSTEMS
▪GENERAL
(-) Chills (-) Malaise (-) Fever (-) Headache

▪INTEGUMENTARY
(+) hyperpigmentation on upper and lower extremities (neck and both
lower legs) (-) Lesions (-) Pruritus
▪HEAD AND NECK
(-) Hearing loss (-) Eye pain (-) Blurring of vision (-) Vertigo
(-) Ear discharge (-) Ear pain (-) Tinnitus (-) Nasal discharge
(-) Nasal congestion (-) Epistaxis (-) Hoarseness (-) Sore throat

• GASTRO-INTESTINAL
(-) Dysphagia (-) Odynophagia (-) Hematemesis
(-) Diarrhea (-) Constipation (-) Steatorrhea
(-) Melena (-) Hematochezia (-) Abdominal pain
▪GENITOURINARY
(-) Dysuria (-) Anuria (-) Polyuria (-) Hematuria
(-) Incontinence (-) Discharge (-) Flank/suprapubic pain
(-) Dribbling (-) Urinary frequency

▪HEMATOLOGIC
(-) Pallor (-) Easy bruisability

 ENDOCRINE
(-) Polyuria (-) Heat or cold intolerance (-) Polydipsia
(-) Polyphagia

▪NEUROPSYCHIATRIC
(-) Syncope (-) Seizures (-) Paralysis (-) Depression
(-) Delirium (-) Hallucination (-) Tremors
 PHYSICAL
EXAMINATION
 GENERAL SURVEY

• unkempt
• endomorph
• Noted slight difficulty in ambulating
• conscious, coherent, tachycardic, tachypneic
but not in distress
VITAL SIGNS
• BP: 140/90 mmHg
• CR: 102 bpm
• RR: 31 cpm
• Temp: 36.7°C
• SpO2: 85-86% at room air
• Height: 152.4 cm
• Weight: 95 kg
• BMI: 40.94 (Obese II)
 SKIN

• Skin is brown in color with noted hyperpigmentation on neck

and both lower extremities, warm to touch, and has good
turgor and elasticity.
• (+) multiple round to oval hyperpigmented macules and
papules measuring approximately 2-5mm uniformly
distributed on face, upper and lower extremities.
• Nails are long and dirty.
• Capillary refill is less than 2 seconds.
• no clubbing of the fingernails.
 HEENT

• Head: Normocephalic without tenderness, lumps, or lesions

• Eyes: anicteric sclereae, pink palbebral conjunctiva, (+) congenital

flesh-like mass on lateral side of the right eye approximately 0.5cm

• Ears: Intact gross hearing, (+) minimal retained cerumen on both ears

• Nose: Symmetric and midline. Nasal septum midline. No Nasal discharge,

No masses and no Polyps

• Neck: No cervical lymphadenopathy, (+) hyperpigmentation on

posterior neck

• Mouth: Pink oral mucosa, (+) dental carries, tongue and uvula midline
CHEST AND LUNGS

• Skin is brown in color, no visible subcutaneous vessels.

• Chest is elliptical in shape, symmetrical with no gross deformities.
• Anterior-posterior diameter is less than the lateral diameter.
• No intercostal retractions or bulging, no narrowing or widening of
the intercostal spaces.
• Asymmetrical chest expansion, (+) lagging on left side, decrease
tactile fremitus on the left, Right mid-base and Left basal lung fields
are dull upon percussion.
• decrease breath sounds over all lung fields.
CARDIOVASCULAR

• No bulging, no depression, neck vein distention cannot be

totally determined, precordium is adynamic.
• Apex beat is at 6th ICS LMCL.
• No heaves, lifts, or thrills noted.
• Equal and strong peripheral pulses noted bilaterally.
ABDOMEN

• Globular with normoactive bowel sounds

• Non-tender in all quadrants
• No masses.
EXTREMITIES

• Full equal pulses

• (-) cyanosis
• (+) Grade 2 bilateral pitting edema
Mental Status F: Awake, alert, coherent, follows command, good insight and
Exam judgment
T: Intact immediate, remote, and recent memory; Oriented to time,
place, person.
O: Cannot be assessed
P: No R-L disorientation, acalculia, agraphia or finger agnosia

CN I: (-) anosmia; able to identify test substance (1/1)

Cranial Nerves CN II: pupil 2-3mm SRTL, OD, (+) ROR, OD; 2-3mm NRTL, OS, (-) ROR
CN III, IV, VI: Primary gaze midline, (-) nystagmus, (-) diplopia
CN V: intact and equal sensation on V1, V2, V3, good temporalis and
masseter tone, (+) corneal reflex
CN VII: No facial asymmetry
CN VIII: Intact gross hearing,
CN IX, X: Intact gag and swallow reflex
CN XI: Good shoulder shrug, good SCM tone and trapezius tone
CN XII: Tongue midline with no deviation, fasciculation or atrophy
 R L
MOTOR UE 5/5 5/5
LE 5/5 5/5
R L
UE 100% 100%

SENSORY LE 100% 100%

Proprioception: Intact
Vibration: Intact
Pinprick Sensation: Intact
 REFLEXES 2+ on all extremities, (-) Babinski, (-) Clonus

CEREBELLAR (-) Dysdiadokinesia; Normal gait

MENINGES (-) Brudzinski, (-) Kernig’s, (-) Nuchal rigidity

 Salient Features
• 62 year old
• Cc: Cough
• (+) HTN: with maintenance but non-compliant
• Previous heavy smoker with 192 pack years
• Chronic alcoholic beverage drinker
Alcohol Use Disorder Identification Test Concise (AUDIT-C) score of 9----
Likely heavy/hazardous drinking
• Weight: 95 kg
• BMI: 40.94 (Obese II)
• BP: 140/90 mmHg
• CR: 102 bpm
• RR: 31 cpm
• Temp: 36.7°C
• SpO2: 85-86% at room air
• Apex beat 6th ICS
• (+) lagging on left side,. Right mid-base and Left basal lung fields
fields are dull upon percussion. Decrease breath sounds over all
lung fields
• (+) Grade 2 bilateral leg edema
September 18, 2018 – First Visit
S O A P
BP: 140/90 mmHg CHF NYHA IV #1: CHF
CR: 101 bpm Obesity Dx: ff-up official 2D echo result
RR: 31 cpm HTN st. II- TX:
Cc: cough Temp: 36.7°C uncontrolled NTX: avoid strenuous activities
SpO2: 85-86% at room air COPD
#2: Obesity
3 days prior to o Anictric sclerae, pink
Dx: none
consult, patient palpebral
Tx: none
experienced non- conjucntiva
o (-) NAD, (-)CLAD, (+) NTX:
productive cough,
with slight shortness hyperpigmented • Diet modification: low salt, low fat,
Low Purine Diet
of breath, no posterior neck, (+)
associated fever, multiple
and colds. No hyperpigmentede #3: HTN st. II-uncontrolled
medications taken macules on both Dx: repeat Blood Chemistry (FBS, TLP,
upper and lower Na, K, Cl, TPAG, SGOT, SGPT, BUN,
and no consult was Crea, BUA), CBC
done. extremities
o (+) Decreased breath
sounds on ALF, (+) #4 COPD:
dullness on percussion - Deep breathing Exercise (pursed-lip
breathing)
on Right mid-base LF
and Left LF
o (+) edema (+)
hyperpigmented lower
extremities (distal legs)
September 19, 2018
S O A P
BP: 140/90 mmHg CHF NYHA IV #1: CHF
CR: 109 bpm Obesity Dx: ff-up 2D echo result
RR: 33 cpm HTN st. II- TX: Prescribed with diuretics
Temp: 36.5°C uncontrolled NTX: avoid strenuous activities
Cc: cough SpO2: 84-85% at room air COPD
#2: Obesity
o Anictric sclerae, pink
Dx: none
palpebral
Tx: none
conjucntiva
o (-) NAD, (-)CLAD, (+) NTX:
hyperpigmented • Diet modification: low salt, low fat,
Low Purine Diet, limit intake of
posterior neck, (+) water to 1L/day
multiple - Regular exercise program
hyperpigmentede
macules on both
upper and lower #3: HTN st. II-uncontrolled
extremities Dx: repeat Blood Chemistry (FBS, TLP,
Na, K, Cl, TPAG, SGOT, SGPT, BUN,
o (+) Decreased breath Crea, BUA), CBC-DONE
sounds on ALF, (+) TX: start:
dullness on percussion
• Amlodipine 10mg/tab 1 tab OD
on Right mid-base LF
• Atorvastatin 80mg/tab 1 tab
and Left LF ODHS
o (-) edema (+)
hyperpigmented lower • Losartan 50mg/tab 1 tab OD
extremities (distal legs) • Furosemide 40mg/tab 1 tab OD
with BP precaution
#4 COPD:
- Deep breathing Exercise (pursed-lip
breathing)
September 26, 2018

S O A P
 Patient seen and  Sits comfortably CHF NYHA IV  Advised to continue
examined  VS: Hypertension Stage II- medications given
 No subjective  BP: 130/80mmHg uncontrolled  Advised proper
 PR:99 hygiene and diet
complaints Obesity
 RR: 24  Advised about their
 “Nakakaramdam COPD home environment
ako ng ginhawa,  O2 Sat:90%
kaya ko ng
o Anictric sclerae, pink Meds:
humiga ng hindi
nakatagilid tulad palpebral conjucntiva To start
ng dati at mas o (-) NAD, (-)CLAD, (+) • Metoprolol
hyperpigmented posterior 50mg/tab BID
hindi ako hingal
neck, (+) multiple • Doxofylline
ngayon” 400mg/cap 1 cap
hyperpigmentede macules
on both upper and lower OD
extremities
o (+) clearing of breath
sounds on ALF, (-) edema
(+) hyperpigmented lower
extremities (distal legs)
September 28, 2018

S O A P
 Patient seen and  Sits comfortably outside CHF NYHA IV  Advised to
examined their house Hypertension Stage II- continue
 VS: medications given
 Complains uncontrolled
 BP: 130/80mmHg  Advised proper
increase Obesity hygiene and diet
episodes of  PR:103 COPD
 RR: 27  Advised about their
urination (patient home environment
taking  O2 Sat:92%
furosemide)
o Anictric sclerae, pink
 Still gets easily
palpebral conjucntiva
tired but patient
o (-) NAD, (-)CLAD, (+)
verbalized “mas hyperpigmented posterior
okay neck, (+) multiple
pakiramdam ko hyperpigmentede
ngaun” macules on both upper
and lower extremities
o (+) clearing of breath
sounds on ALF, (-) edema
(+) hyperpigmented lower
extremities (distal legs)
October 1, 2018

S O A P
 Patient seen and  Awake and sits CHF NYHA IV Continue present
examined comfortalby Hypertension Stage II- medications
 VS: uncontrolled
 BP: 140/90mmHg Obesity
 PR: 98 COPD
 RR: 27
 O2 Sat:88-89%

o Anictric sclerae, pink

palpebral conjucntiva
o (-) NAD, (-)CLAD,
o (-) retractions, CBS
o (+) bipedal edema edema
October 4, 2018

S O A P
 Patient seen and  Awake and sits CHF NYHA IV Continue present
examined comfortalby Hypertension Stage II- medications
 Cc: Difficulty of  VS: uncontrolled
Breathing  BP: 150/90mmHg Obesity Hold:
 PR: 50-60 COPD 1. Metoprolol
 RR: 35 50mg/tab BID
 O2 Sat:85-86%
To start
o Anictric sclerae, pink 1. Losartan + HCTZ
palpebral conjucntiva 50/12.5 tab 1 tab
o (-) NAD, (-)CLAD, OD
o (-) retractions, (+)
decrease BS R>L
o (+) Grade 2 bilateral
edema edema
 FINAL DIAGNOSIS

CHF NYHA IV
Hypertension Stage II-uncontrolled
Obese Class II
COPD
Diagnostics
 Laboratory Test
09.18.18
Test Result Normal

FBS 6.21 mmol/L 3.89-5.50

Total cholesterol 5.10 mmol/L 0-5.17

HDL 1.07 mmol/L 1.04-1.55
LDL 2.94 mmol/L 1.89-3.09
VLDL 1.09 mmol/L 0-1.0
Triglycerides 2.39 mmol/L 0-1.69
Blood Uric Acid 425.00 mmol/L 150-350
Total Protein 94.00 g/L 64-83
Albumin 34.00 g/L 35-50
Globulin 60 g/L 23-35
A/G Ratio 0.57
 Laboratory Test
09.18.18
Test Result Normal
Na 141. 00 mmol/L 136-145

K 4.21 mmol/L 3.5-5.1

Cl 101.00 mmol/L 98-107
SGOT 22.00 U/L 5-34
SGPT 20.00 U/L 0-55
BUN 4.90 mmol/L 3.5-7.2

94.70 umol/L
Crea 49-90
eGFR 55.1 mL/min/1.73m2

Staging of CKD

Stage 1: kidney damage with normal or increased GFR (>90 mL/min/1.73m2)

stage 2: Mild reduction in GFR (60-89 mL/min/1.73m2)
Stage 3a: Moderate reduction in GFR (45-59 mL/min/1.73m2)
Stage 3b: Moderate reduction in GFR (30-44 mL/min/1.73m2)
Stage 4: Severe reduction in GFR (15-29 mL/min/1.73m2)
Stage 5: kidney failure (GFR 2< or dialysis)
Radiographic Image

January 2018
Interpretation:

• Shows prominent pulmonary vascular markings,

bilaterally. Consider pulmonary congestion.
• There is no interval change in the previously noted right-
sided minimal pleural effusion versus thickening.
Radiographic Image

August 2018
Interpretation:

• Compared with the previous chest radiograph dated 1/12/18,

the present examination again shows prominence of
pulmonary vascular changes in both lungs. Bilateral
pulmonary congestion/edema is considered. presence of
concomitant pneumonia is not entirely excluded.
• There is no interval change in the previously noted right-sided
minimal pleural effusion versus thickening. Due to its
chronicity, pleural thickening is now considered. The left
lateral costophreninc sulcus is now indistinct. Minimal pleural
effusion versus thickening is considered.
• Same degree of cardiomegaly with left ventricular
configuration and atherosclerotic changes of the aorta is
noted.
• The rest of the chest findings remain essentially the same.
 2D Echo with Doppler Study
January 12, 2018

Conclusion:
Technically difficult study
Normal left ventricular dimension with good wall
contractility and adequate over-all systolic function

**since our patient has BMI of 40.94, TEE or Transesophageal Echocardiography is more
preferred procedure**
 Transesophageal Echocardiography or TEE

Involves mounting transducer at the end of the flexible endoscope

and passing and passing it through the esophagus to position it
closer to the heart. TEE provides higher resolution of the posterior
cardiac structure making it ideal for viewing atria, cardiac valves
and aorta.
 Biopsychosocial
Biological Psychosocial

• Congestive Heart Failure • Financial constraints

NYHA IV • Lack of open communication in
• Obesity the family
• Hypertension Stage II, • Non compliance to medications
uncontrolled and follow ups
• COPD • Lack awareness of importance of
annual physical examination
 FAMILY
ASSESSMENT
TOOLS
FAMILY GENOGRAM
1980
FAMILY MAP
1980
FAMILY STRUCTURE AND
FUNCTION
• According to internal structure:
• EXTENDED FAMILY
• According to authority:
• EQUALITARIAN
• According to residence:
• NEOLOCAL
• According to family setup:
• DEMOCRATIC PARENTING
• FAMILY SOCIAL CLASS
• The family belongs to the middle socioeconomic
class.

• FAMILY FUNCTION

• BREADWINNER: JUNEL
• DECISION MAKER: JOHNY
• CAREGIVER: MARY JANE
Impact of Illness:

The family was greatly affected in terms of

financial and emotional aspects when Johny got
hospitalized and underwent surgical operation.
Their small sari-sari store went on bankruptcy and
they had some confrontation with other members
of the family but eventually they deal with the
problem as a family and recovered
What problems does this phase in the life cycle
raise for them? Briefly explain.

• The patient has difficulty maintaining her own

functioning due to physiological decline
Does the family feel these problems were dealt
with satisfactorily? Briefly explain.

• The children of the patient especially Maryjane

helps her in looking after the patient by
assisting her to walk, helps her do household
chores.
 What does each member expect from each other, their
parent/s or head of the family or spouse or others?

Parents expect their children to help them with the

finances and that their grandchildren will do good
in school so that they will have a better life in the
future

Children and grandchildren expect emotional and

moral support as they start learn to learn to ive their
life on their own
 d) What does the parent/s (or other members)
expect from their child/children (each other)?

• Our index patient expects that their children

could take care of her
• Our index patient expects that her grandchildren
will finish their studies
 e) Are these expectations realistic? If yes, how can
these be achieved? If no, why not? What are the
obstacles?

Yes.
Through behavioral change such as family support
system.
 ECONOMIC STATUS
SOURCE OF INCOME
Sari-sari store 15,000/month
Junel (7-eleven) 18,000/month
Jonathan (Maintenance in a 9,000/month
restobar)
Robert (Construction in a company) 11,000/month

total 53,000/month

MIDDLE CLASS- based on 2012 Family Income &

Expenditure Survey, Philippine statistics Authority
ECONOMIC STATUS
Water, 1200

Sari-Sari Store,
3000
Food, 9000
Electricity, 4000

17,200
 EXPENSES
Water
7%

Sari-Sari Store
18%

Food
52%

Electricity
23%
FAMILY LIFELINE
 YEAR EVENT
1980 Civil wedding
1986 Death of 3rd child due to complications of German Measles

1986 Birth of 5th child

House at Escopa II was destroyed due to fire
1989 Moved to Escopa III
Church wedding
2002 Birth of first grandchild
April 2016 Husband underwent operation for bowel perforation
Experienced financial difficulties due to hospital expenses
May 2016

Youngest son graduated college

May 2017

Patient was admitted at QMMC due to aspiration

December 2017
pneumonia, CHF
Patient was brought to the ER due to DOB, but was
August 2018
eventually sent home.
FAMILY APGAR
 Family APGAR
Sagutin ang mga sumusunod ayon sa relasyon ninyong mag- Mary Index
anak Jane Patient
(6th
child)

A Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa aking 2 1

pamilya sa oras ng problema.

P Ako’y nasisiyahan sa paraang nakikipagtalakayan sa akin 2 2

ang aking pamilya tungkol sa aking problema.

G Ako’y nasisiyahan at ang aking pamilya ay tinatanggap at 2 2

sinusuportahan ang aking mga nais na gawin patungo sa
mga bagong landas para sa aking ikauunlad.

A Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya 1 2

ang kanilang pagmamahal at nauunawaan ang aking
damdamin katulad ng galit, lungkot at pag-ibig.

R Ako’y nasisiyahan na ang aking pamilya at ako ay 1 2

nagkakaroon ng panahon sa isa’t isa.

Total Score 8 9

Interpretation: ??? Interpretation na lang…

Highly functional
 8-10: Highly functional
 4-7: Moderately dysfunctional
 <4: Severely dysfunctional
• Kung hindi ka nakakahingi ng tulong sa iyong
sariling pamilya, kani-kanino ka humihingi ng
tulong? Anong uri ng tulong (emotional,
physical, spiritual, financial, others)?

Pangalan Relasyon Uri ng Tulong

na Hinihingi
“Bumbay" Financial

Carlos de kaibigan Financial

Guzman
1.In the future, what is the family’s primary (most
important) goal?
- Good health and well-being for the whole
family and maintenance of good relationship
within the family.
2. Do all the members work together toward these
goals/desires? How? If not, what seems to be the
hindrance for working together? Who is the main
person responsible for these goals?
- No for the good health but yes for the relationship.
- For the health, financial constraints remain a
hindrance for the attainment of this goal. But the
family is able to maintain a good relationship.
- Junell and Mary Jane
3. Is there any history of alcoholism, gambling, drug
abuse/dependency, domestic violence, or any
illegal and immoral acts? Has something been
done to address this problem?
- Yes for alcoholism.
- Family members have advised the patient to stop
drinking.
SCREEM
PARAMET STRENGTH
ER
Social [✔] Open intrafamilial lines
of communication
[✔] Absence of
animosity/rivalry
[✔] Healthy/supportive
intrafamilial relationships
[✔] Healthy/supportive
extrafamilial relationships
Others:
_________________________
WEAKNESS
[ ] Lack of intrafamilial lines
of communication
[ ] Presence of
animosity/rivalry
[ ] Unhealthy intrafamilial
relationships
[ ] Unhealthy extrafamilial
relationships
Others:
___________________________
Cultural [✔] Absence of or very [ ] Presence of some
few beliefs/practices that beliefs/practices that are
are unacceptable to our unacceptable to our
culture or negatively culture or negatively affect
affect way of living (e.g., way of living. (Specify
.institutionalization of these practices)
elderly, dependency of __________________________
married children to
parents, value for
education, does not
advocate family
closeness, seeking help
from traditional healers,
etc.)
Others:
_________________________
Religious [ ] Spirituality is positively
influencing way of life
[✔] Practicing one’s faith,
enduring because of his
faith
Others:
_________________________
[ ] Spirituality is negatively
influencing way of life
[ ] Not practicing one’s
faith
Others:
__________________________
Educational [✔] Level of [ ] Level of education is a
education is not a hindrance to achievement,
hindrance to livelihood, success
achievement, [ ] Level of education
livelihood, success hinders comprehension of
[ ] Level of education most challenging
facilitates circumstances
comprehension of Others:
most challenging __________________________
circumstances
Others:
_____________________
Economic [✔] Ability to allocate [ ] Inability to allocate
funds appropriately funds appropriately
[✔] Ability to make [ ] Inability to make ends
ends meet most of the meet most of the time
time Others:
Others: ________________________
______________________
Medical [ ] Good compliance [✔] Poor compliance with
with medical medical management
management [✔] Inappropriate medical
[ ] Timely and consultation
appropriate medical [✔] Not aware or does not
consultation practice wellness and
[ ] Aware and practices environmental sanitation
wellness and Others:
environmental sanitation _________________________

Others:
_______________________
 To what groups or organizations do the family members
belong?
Escopa Barangay Health Clinic, Senior Citizen benefits (QMMC OPD


Clinic and free laboratories)

 What national/community resources has the family used?
“CIBAC”
 What are the primary concerns of the family with their
immediate environment?
 Family lives in a crowded area where one can easily be
contacted with different diseases, house is not well
maintained, pets and coal products are inside their house.
 What are the positive and negative points of the
community where the family resides?

Negative Positive

 Gossip
 Noise from drinking
sessions of neighbors
 Occasional fighting of
neighbors
 “Bayanihan”
 Barangay Health Clinic
 Social Service /Politicians'
Medicine Assistance
SCREEM-RES
SCREEM Family Resource Survey (SCREEM- Strongly Agree DisAgree Strongly
RES) Questions Agree (2) (1) Disagree
(3) (0)

Social


>We help each other in our family
>We are helped by friends and other members of
the community

Cultural


>Our Culture gives our family strength
>A culture of helping and cooperation in our
community helps our family
SCREEM Family Resource Survey (SCREEM-RES) Strongly Agree DisAgree Strongly
Questions Agree (2) (1) Disagree
(3) (0)

Religious


>Our faith and religion helps our family
> we are helped by members of our church or other
religious group


Economic
>Our family’s savings is adequate for our needs
>Our Family’s income is adequate for our needs

Educational


>Our education/knowledge is adequate to understand
information about the illness
>Our education/knowledge is adequate to care for the
patient

✓
Medical
>It is easy to access medical help in our community
>We are helped by doctors nurses and health workers

TOTAL: 10
 Interpretation:
SCORE INTERPRETATION

13-18 Adequate family resources

7-12 Moderately inadequate family resources

0-6 Severely inadequate family resources

Score: 10
(Moderately inadequate family resources)
ECO-MAP
 CHURC HEALTH
H CARE

SCHO
WORK
OL
PABLO
EXTEN
RECRE
DED
ATION
SOCIAL FAMILY
FRIEND
WELFA
S
RE
 Work Index patient earns some income from massaging clients
at home; youngest child has a regular job
Church Index patient is unable to go to church due to easy
fatigability, but claims to attend the mass via the
television; other members of the family goes to the
church weekly
Healthcare Index patient is unable to have regular check ups despite
the close proximity to the health care center and hospital
School Grandchildren regularly goes to school
Extended Family Relatives frequently visits the family; no issues with the
relatives
Friends Good relationship with friends; receives emotional
support from them
Social Welfare No issues with the neighbors
Recreation Other members of the family occasionally visits the park
as a form of recreation; index patient usually stays home
and watch tv
ENVIRONMENTAL ASSESSMENT
 MANAGEMENT GOALS
MANAGEMENT
SHORT TERM GOALS

Educate the patient on her current conditions and

complications

Encourage the patient to do simple exercises (DBE) and limit

intake of fluids (max 1L per day)
Educate the patient regarding her disease and be able to know
the importance of diagnostics requested to her.
 MANAGEMENT GOALS
LONG TERM
Participate in activities or organizations for senior citizens
offered in the community to promote social interactions.
Patient will be able to maintain effective social interaction with
family members or neighbors.

Maintaining overall health through regular medical care,

proper diet and exercise, and using complementary health
approaches as appropriate to address specific health needs.

Prevent chronic long term symptoms of CHF, hypertension,

obesity and exacerbations of COPD that may interfere with
daily living
 FAMILY HEALTH CARE PLAN
FAMILY MEMBER PROBLEM/S RECOMMENDATIONS
AGE, GENDER, CS (MEDICAL/PSYCHOSOCIAL) (MEDICAL/WELLNESS/PSYCHOSOCIAL)

1. Elenita CHF NYHA IV Problem #1: CHF NYHA IV

Obesity Dx: none
Tx:
Hypertension Stage II-
o Amlodipine 10mg/tab, 1 tab OD
uncontrolled
o Atorvastatin 80mg/tab 1 tab ODHS
COPD o Metoprolol 50mg/tab BID --- HOLD
o Losartan + HCTZ 50/12.5 tab OD
NTx:
o Avoid strenuous activities
o Limit water intake to 1L/day

Problem #2: Obesity

Dx: none
Tx: none
NTX:
• Diet modification: low salt, low fat, Low
Purine Diet
• Regular exercise program
 Exercise Program
• Exercise therapy should include sessions of 20–30 minutes
performed three to five times a week. Exercise is an
intervention that is relatively low-cost, easily accessible,
and easy to perform.

Mentzer, G.G. & Auseon, A.J. (2012) Exercise Capacity in Chronic Heart Failure. US
Cardiology Volume 9 - Issue 1.
 Exercise Program
• The 6MWT is a practical simple test that requires a 100-ft hallway but no
exercise equipment or advanced training for technicians. Walking is an
activity performed daily by all but the most severely impaired patients.
This test measures the distance that a patient can quickly walk on a flat,
hard surface in a period of 6 minutes (the 6MWD).
• It evaluates the global and integrated responses of all the systems
involved during exercise, including the pulmonary and cardiovascular
systems, systemic circulation, peripheral circulation, blood,
neuromuscular units, and muscle metabolism.

American Thoracic Society. (2002). ATS Statement: Guidelines for the Six-Minute Walk Test.
American Journal of Respiratory and Critical Care Medicine, Vol 166. pp 111–117
 Exercise Program
• A gentle individualized gradual mobilization of the patient
(known as ‘calisthenic exercises’) is advisable as a prologue
and preparatory form of exercise, especially for severe HF
patients with physical deconditioning or cachexia or after
recent clinical instability.
• A variety of simple movements, performed without weights
or equipment, intended to increase body strength and
flexibility using the weight of one’s own body for resistance, in
combination with stretches, are advisable in these conditions.
These movements should be initiated as soon as possible,
since they are easy to perform and well accepted. They
improve movement co-ordination and respiratory capacity.

Piepoli et al. (2011). Exercise training in heart failure: from theory to practice. A
consensus document of the Heart Failure Association and the European Association for
Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure, 13, pp.
347–357
 Exercise Program

• Breathing exercises for 15–30 min, 5x/week for the first 3

weeks after which they were performed every other day
for 12 more weeks and included stretching, yoga, PLB,
and “strengthening of respiratory muscles”.

Cahalin, L. P., & Arena, R. A. (2015). Breathing Exercises and Inspiratory Muscle Training
in Heart Failure. Heart Failure Clinics, 11(1), 149–172. doi:10.1016/j.hfc.2014.09.002
 Exercise Program

• In more deconditioned patients, it is recommended to start

low and go slow (i.e. at low intensity for 5–10 min twice a
week). If well tolerated, first the training duration per session
and then the numbers of sessions per day are increased,
aiming at 20–60 min on 3–5 days per week at moderate-to-
high intensity with indefinite programme duration.

Piepoli et al. (2011). Exercise training in heart failure: from theory to practice. A
consensus document of the Heart Failure Association and the European Association for
Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure, 13, pp.
347–357
 Exercise Program
• Patients perform dynamic strength exercises slowly, on specific
machines at an intensity usually in the range of 50-60% of one repetition
maximum; work phases are of short duration (< or =60 seconds) and
should be followed by an adequate recovery period (work/recovery ratio
>1:2).
• Patients with a low cardiac reserve can use small free weights (0.5, 1 or 3
kg), elastic bands with 8-10 repetitions, or they can perform resistance
exercises in a segmental fashion.
• Based on recent scientific evidence, the application of specific resistance
exercise programmes is safe and induces significant histochemical,
metabolic and functional adaptations in skeletal muscles, contributing to
the treatment of muscle weakness and specific myopathy occurring in
the majority of CHF patients.

Volaklis KA1, Tokmakidis SP. (2005). Resistance exercise training in patients with heart
failure. Sports Medicine, 35 (12), pp. 1085-103.
 Exercise Program
• Contraindications for participation in an exercise training
programme (Cardiac):
• Decompensated or unstable heart failure, New York Heart Association
functional class IV
• Exercise training-induced myocardial ischaemia, hypotension,
nonsustained or sustained ventricular tachycardia, atrial fibrillation
(until resolved)
• Severe valvular dysfunction (regurgitation or stenosis)

Maeyer, C.D., Beckers, P., Vrints, C.J., & Conraads, V.M. (2013). Exercise training in
chronic heart failure. Therapeutic Advances in Chronic Diseases 4(3), pp. 105–117
 FAMILY HEALTH CARE PLAN
FAMILY MEMBER PROBLEM/S RECOMMENDATIONS
AGE, GENDER, (MEDICAL/PSYCHOSOCIAL) (MEDICAL/WELLNESS/PSYCHOSOCIAL)
CS
1. Elenita CHF NYHA IV Problem #3: Hypertension st. II
Dx: repeat after 3 months
Obesity TX:
Hypertension Stage II- • Continue medications:
uncontrolled o Amlodipine 10mg/tab, 1 tab OD
o Atorvastatin 80mg/tab 1 tab ODHS
COPD o Metoprolol 50mg/tab BID ---HOLD
o Losartan + HCTZ 50/12.5mg tab OD
NTx:
• For daily BP monitoring
• DASH DIET (more fruits and vegetables, whole
grain foods, fish, poultry, nuts and fat free or low
fat free or low fat milk products).It recommends
reducing foods high in saturated fats, sweets,
sugary drinks, sodium and red meats
FAMILY MEMBER PROBLEM/S RECOMMENDATIONS
AGE, GENDER, (MEDICAL/PSYCHOSOCIAL) (MEDICAL/WELLNESS/PSYCHOSOCIAL)
CS

1. Elenita Problem #4: COPD

Dx: none for now
Tx:
1. Doxofylline 400mg/cap 1 cap OD
2. Salmeterol + Fluticasone inhaler 2 puffs BID

NTx:
Deep breathing exercise (pursed lip breathing)

Others:
• Plan for referral to Ophthalmology Department
to evaluate her sight and the congenital flesh-
like mass on the lateral side of her right eye.
• Referral to Dermatology department regarding
few elevated papules that is hyperpigmented
on her face.
• Plan to immunize the patient with Influenza and
Pneumonia vaccine.
• Plan to refer the patient in our Dietary
department to properly manage her diet plan
based on her needs.
 FAMILY HEALTH CARE PLAN
FAMILY PROBLEM/S RECOMMENDATIONS
MEMBER (MEDICAL/PSYCHOSOCIAL) (MEDICAL/WELLNESS/PSYCHOSOCIAL)
AGE, GENDER,
CS

2 Johnny Elevated Blood pressure  Smoking cessation

 LSLF diet
 Work-up regarding elevated blood
pressure
3 Mary Jane Elevated Blood Pressure  LSLF
 Work-up regarding elevated blood
pressure
 Exercise
4 Junel  ESSENTIALLY WELL  Balanced diet
 Exercise
Group B