by:Angustia, Ayes, Chan, Co, Garcia, Macapinlac, Tumibay, Vega

23 July 2010

Barely a kilometer from the finish line...

OutlineI. Characteristics of the New Model

of Practice for Family Medicine

II. The Family Case Presentation

I. Characteristics of the New Model of Practice for Family

MedicineA. A personal medical home for each patient

B. Patient-centered care

C. A team approach to care

D. Elimination of barriers to care

E. Advanced information systems, including integrated electronic health records (EHRs)

F. Redesigned, functional offices

G. Whole-person orientation

H. Care provided within a community context

I. Emphasis on quality and safety

J. Enhanced practice finances (through operating efficiencies and new revenue streams)

K. A commitment to provide family medicine's “basket of services”

II. The Family CP

A. Introduction

B. Clinical History of the patient

C. Heat stroke

D. Family Assessment Tools

E. Results of Assessments

F. Impact of illness to the patient and the family

G. Family System Theories

H. Conclusion and Recommendations

II. The Family CP

A. Introduction

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

Purpose of the CP Why was this case chosen?

A sudden situation Timeliness Family Medicine PH significance

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

Focus of the CP

Impact of illness to the patient and family

Coping mechanism Family dynamics Social resources

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

Chief complaint (CC)

Loss of consciousness (LOC) a concern of the family

II. The Family CP

B. Clinical history of the patient

III. Clinical History of the Patient

I. Course of illnessA. HistoryB. PE C. Diagnostics and ResultsD. Diagnosis E. Course in the ER, ICU

Course of illness

A.History

B.PE

C.Diagnostics and Results

D.Diagnosis

E.Course in the ER, ICU

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

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

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

II. The Family CP

C. Heat stroke

Heat Stroke Definition Epidemiology and Incidence Pathophysiology Differentials Diagnostic work-ups Management – pharma (include MOA if

applicable) and non-pharma Prognosis Prevention PH

Heatstroke

Most severe and deadly heat-related illness

Definition: Body temp 41C assoc. w/ neurologic dysfunction

2 types Classic Exertional heatstroke

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

Pathophysiology

Imbalance of heat gain and heat loss Excessive heat denatures proteins

in body HSP and inflammatory cascade

more damage to body

Differentials

Amphetamine or cocaine toxicity Myocardial infarction Stroke Delirium tremens

Work-up

CBC Cardiac markers Urinalysis Muscle function test (CK, lactate

dehydrogenase) ECG CXR CT scan

Treatment

Medical EMERGENCY THERAPEUTIC HYPOTHERMIA

Treatment

Benzodiazipine Hydration Decrease temperature

Prevention and PH

Preventable disease EDUCATION = most important tool

II. The Family CP

D. Family assessment tools

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

Family Profile

Name of Family Member

Age/Sex Occupation

Rudy Fuentes Computer Industry

Mrs. Rudy Fuentes

Roy Fuentes 34/M Sales Manager

? Fuentes (Younger brother)

M

Takako Fuentes F Housewife

Raphael Fuentes 8/M

Therese Fuentes 4/F

37

8 4

I

II

III

?

Family Genogram

Family Structure

Nuclear Family

Family Life Cycle Stage

Family with young children Parent team approach Getting used to new roles Formation of new alliances

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

I

II

III

Family Map

37

8 4

?

Dynamics of the family

Alliances and conflicts that will compromise cooperation in patient care

Strong alliance with young wife

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

Time line and phase of illness

Pre-diagnosisw/ symptoms

Pre-terminal

Chronic‘long haul’

Initial adjustmentperiod

Mourning andResolution of loss

Crisis Chronic Terminal

DeathDiagnosis

PHASES

TIMELINE

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”

SCREEM

PARAMETER

RESOURCE PATHOLOGY

Social •Intact family despite geographic distance•Presence of good channels of communication•Bonding with family through sports•Involvement in the upbringing of his children•Extracurricular activities: Running, Photography, Airsoft

• Questionable relationship between in-laws

• may uncover hidden dysfunction

Cultural • Not assessed • not evident at time of assessment

Religious •Christian • not evident at time of assessment

SCREEMPARAMETER

RESOURCE PATHOLOGY

Economic • Financially stable – IT Manager for HP (10 yrs)•Can afford to send son to LSGH•Can afford to travel •Can afford extracurricular activities

not evident at time of assessment

Educational •RF is a Computer Engineering graduate

• May not have fully been aware of physical limits and the harmful effects of pushing himself to the limits

Medical • Medical Services available at place of work• Annual medical check-up available as part of company package• High probability of availability of health insurance through company

• No available first aid on-site at Milo Run• No response from EMS on-site

Four Areas of Assessment

A. Type of IllnessB. Flexibility and Openness of the

familyC. Stage at which illness occursD. The role that the sick person plays

A. 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

B. 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

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

C. 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

II. The Family CP

E. Assessment Results

Assessment Results

- family dynamics of the Fuentes’ is rather new

- Changes: wife, children, brother, R.F.”s father

- disruption of the family life cycle- coping mechanisms

- intact family clan- religion and faith

II. The Family CP

F. Impact of illness to the patient and the family

Impact of illness to the patient and the family

Shock/suddenness Denial Questions

Resources to tap Family ties Family Med doctor

Need for help assessment SCREEM analysis

II. The Family CP

G. Family system theories

Family Issues

Nature of onset Change of roles and responsibilities External factors Denial and negotiation Family stage factors

Nature of Onset

Acute and rapid Little time to prepare emotionally

and psychologically Decision making thrown upon wife Emotional toil and fatigue “Unfair”

Change of Roles & Responsibilities

New gatekeeper – decisions Wife – new breadwinner “alpha male” role of male son Lolo & Lola – surrogate parents Centripetal

External Factors

Negligence of organizers Lack of prompt recognition of

condition Knowledge of preventability of

incident

Denial and Negotiation

“Unfair” Desire to get to the root of the

“problem” Frustration against organizers Emotions during resuscitation

Family Stage Factors

Family with young children Loss of father-figure Premature onset of roles w/

underlying developmental stage issues (i.e. puberty)

II. The Family CP

H. Conclusion and Recommendations

Recommendations Presence of physician – “I won’t abandon

you” Utilization of skills of the FM doctor

Breaking the bad news Psychosocial contexts

Leveling – bring to light family issues, make clear the current situation of the family

Expectations Goal Setting Follow-up PH

Education Precautionary measures

References Helman RS and Habal R. Heatstroke:

Treatment & Medication. Emedicine. URL: www.emedicine.com. Date accessed: July 22, 2010.

ASMPH Family Medicine Lectures http://www.aafp.org/fpm/2005/0500/p59.html http://www.pinoyfitness.com http://www.google.com http://www.facebook.com/remus.fuentes http://heartofmed.com/category/lectures/ Friendster