OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

FAMILY CASE ANALYSIS

Patients Name:

LAMBERTO AUSTRIA

Date of Visit:

May 15, 2014

Age/Sex:

60/M

Time of Visit:

10:00 AM

Address:

633 Basco St., Intramuros Manila

Initial Impression:

Mixed Wound Infection, distal area, left leg

Diabetes mellitus Type 2, uncontrolled

Resident-in-Charge:

Dr. Janice Paras

Medical Interns-in-Charge:

Ezekiel T. Arteta and Charlene R. Bularan

CLINICAL ABSTRACT

This is a case of a 60 year-old male, married, Filipino, Roman Catholic member, vendor, from Intramuros, Manila. Patient had a chief complaint of plaques.

History of Present Illness:

Patient is as known case of Diabetes Mellitus Type 2 for ~2 years, maintained on Metformin 500mg OD, pre-breakfast, with poor compliance. Last consultation to a Health Center was 6 months prior to visit, allegedly with an FBS of 165 mg/dl (from 185 mg/dl). Patient is in good vital capacity and was apparently well, until

Approximately 1 month prior to visit, patient experienced gradual onset of pruritus on his left foot. No associated numbness, tingling sensation or changes in the skin color of the extremities. Patient only scratch the area, with temporary relief of the symptom. No consult was done, no medications taken.

In the interim, because of the constant scratching of his left foot, the affected area developed reddish ulceration, and eventually into plaques and crusting. Still, no consult done nor medications taken.

Persistence of the symptoms prompted consult.

Past Medical History:

a. Adult Illnesses:

Medical :

No hypertension, Coronary Artery Disease, CVD, PTB, bronchial asthma, pneumonia

No previous hospitalization, trauma or surgery

Surgical :

No previous trauma or surgery.

Psychiatric :

No history of experiencing psychiatric diseases.

b. Immunizations: No History of Adult Immunizations

c. Allergies: No allergy to food or drugs

Family History:

The patient had 11 children, most of which are now married, and are starting their families in Pangasinan and Ilocos. Raymark is the only person that helps the index patient and his wife to their everyday needs. He works as a pedicab driver.

Patient allegedly had a healthy family. No history of hypertension, diabetes, obesity, CAD, CVD, asthma, pneumonia, or any allergy to his children and descendants.

Personal and Social History:

Patient is a known smoker, with 20 packyears. Also, he occasionally drinks alcoholic beverages. He denies illegal drug use. Patient eats three times a day, with preference to vegetable, coffee, and rice.

Patient works as a vendor of street foods (at Round Table). Their source of drinking water is from NAWASA. The garbage is collected daily, and they dont have pets inside their house.

FICA Spiritual History:

FAITH:

He said that if he has problems, he prays to God and goes to the priest for spiritual guidance. However, he rarely hears mass.

IMPORTANCE AND INFLUENCE:

His faith is important to him because it is through his faith that he forgets his problems.

COMMUNITY:

He is not a member of any Church/civic organization.

AWARENESS AND ADDRESSING:

He is aware of his condition and hopes that his healthcare provider will advise him of what can be done for his condition.

Review of Systems:

a. Constitutional: Weight loss was noted after the onset of his diabetes, estimated to have lost 25% of the total body weight. No fever, chills and fatigue.

b. Integument: No dryness, pallor, yellowish discoloration, clubbing of fingers, or hair loss/excessive hair

c. HEENT:

Head: No syncope or history of head trauma was reported.

Eyes: (+) blurring of vision. No double vision, excessive lacrimation, eye redness nor photalgia were reported. The patient does use reading glasses.

Ears: No hearing difficulty, tinnitus, vertigo, infections or discharges.

Nose and Sinuses: No reports on epistaxis, discharge, itching, nasal stuffiness, or itching.

Mouth and throat: No mouth sores, toothache, sore throat, hoarseness of voice or dysphagia was reported.

Neck: No neck pain, lump, nor stiffness.

d. Respiratory: No shortness of breath, cough, colds or hemoptysis was reported

e. Cardiovascular: No chest pain, palpitations, easy fatigability, orthopnea, cyanosis, or paroxysmal nocturnal dyspnea was reported.

Peripheral vascular: No reports of leg cramps, edema or varicose veins.

f. Gastrointestinal: No abdominal pain, changes in appetite, hematochezia, hematemesis, diarrhea, or excessive belching/passing of gas.

g. Renal: There are no dysuria, nocturia, incontinence, urinary urgency, gross hematuria, urinary retention, reduced caliber of force of stream, hesitancy, or dribbling during urination.

h. Genitalia: No pain, itching, or discharge, swelling or ulcers was reported.

i. Hematologic: There is no pallor, easy bruising, or bleeding.

j. Musculoskeletal: No muscle pain, backache, stiffness, joint swelling or joint pain was reported.

k. Endocrine: No polyuria, polydypsia, polyphagia, excessive sweating, or heat/cold intolerance reported.

l. Neurologic: No reports on history of weakness, tremors, seizures, or memory loss.

m. Psychiatric: No hallucination, depressed mood. Not anxious.

Physical Examination:

General Survey:

Patient is awake and cooperative, properly oriented to surroundings, time, place and situation, with appropriate affect and mood. There were no apparent signs of cardiorespiratory distress.

Vital Signs:

Blood Pressure: 100/60 mmHg sitting, right arm

Heart Rate: 67 beats per minute, regular

Respiratory Rate: 18 breaths per minute, regular

Temperature: 36.8C

Anthropometric Measurements: (not assessed)

Skin, Hair and Nails:

Skin is generally warm and dry, and with good turgor. (+) multiple, well-defined, erythematous plaques, topped with crusting, excoriation and ulcers, at the distal aspect, medial leg.

Hair color is black, with average texture, minimal flaking and does not have any pattern of hair loss. No skin discoloration, lumps, scaling nor lesions on the scalp. Nails do not exhibit clubbing and there is absence of cyanosis. Nail beds were pinkish.

Head:

Face is symmetric, without deformities, involuntary movements, tender areas, edema or masses.

Eyes:

Eyes are bilaterally symmetrical, with no inward or outward deviation. Eyebrows are evenly distributed. There is no scaliness of the eyebrows. Eyelids do not have edema and lesions. There are neither widening nor narrowing of the palpebral fissures. Visual fields full by confrontation. Palpebral conjunctivae are pinkish without discharge and lesions; anicteric sclerae, without discharge.

Ears:

Ears are symmetrical with no deformities, lumps and lesions in auricle. No discharge, tenderness, foreign bodies, redness and swelling were noted.

Nose:

Symmetrical with no external deformities. Nasal mucosa is pinkish and has no swelling, bleeding and exudates. No swelling on the turbinates. No septal deviation, inflammation and perforation. No obstruction, congestion, ulcers or discharge

Mouth and Throat

Lips are pinkish without cracking; there were no lumps, ulcers, and scaliness. Oral mucosa is pinkish, without ulcers, white patches and nodules. Gums are pinkish with no swelling or bleeding. Tongue is pinkish, and in the midline. Uvula is in the midline. The tonsils were intact, with a grade of 0, and not inflamed. The posterior pharyngeal wall is non-hyperemic. Also, no exudates were found.

Neck

Trachea is in midline. Neck with full ROM. No tenderness, no masses or scars. Lymph nodes are not palpable. Thyroid is non-palpable. No palpable enlargement of the thyroid gland.

Chest and Lungs

Chest wall is symmetrical with prominent ribs. There is no retraction of interspaces on inspiration, nor use of accessory muscles of breathing upon inspection. Transverse diameter is greater than the anteroposterior diameter.

Upon palpation, there are neither tender areas nor palpable mass on the chest. Respiratory expansion at the 10th rib is symmetric. The left and the right lungs are equally resonant upon percussion. During auscultation, breath sounds are bronchovesicular. There is no bronchophony, egophony, whispered pectriloquy, crackles, stridor, ronchi, nor wheezes.

Cardiovascular

Patient has adynamic precordium. There is no precordial bulge or heave. The chest area is free of lesions or deformities. Upon palpation, there is no thrill or friction rub. Point of maximal impulse is felt on the 4th intercostal space, exactly at the left midclavicular line.

On auscultation, heart sounds were of medium intensity with a normal rate and regular rhythm. S1 is best heard at the apex while S2 is loudest at the base. There are no S3, S4, murmurs, or pericardial friction rub.

Peripheral Vascular:

There is no cyanosis, varicose veins or digital clubbing of fingers. No pretibial edema

Abdomen:

The abdomen is flabby. There are no scars, lesions, striae or dilated veins. The umbilicus is at the midline and not protruding. Flanks were not bulging. There are no irregular contours, discoloration or bulges. Peristalsis and aortic pulsations were not visible.

Normoactive bowel sounds upon auscultation. There were no bruit, friction rub or succussion splash. The abdomen was tympanitic. No muscle tenderness upon palpation, and there is no shifting dullness.

Liver: Liver span dullness is 10 cm at the RMCL. Liver edge is palpable, with smooth contour and without tenderness at full inspiration.

Spleen: The spleen is not palpable.

Kidneys: The kidneys are not palpable, no costovertebral angle tenderness.

Neurological:

Appearance and Behavior:

Patient appears to be alert, and oriented to time place and person. He is able to make eye contact during the interview. He is dressed properly and is sitting down. There were no mannerisms or tics noted.

Speech and Language:

The speech is of adequate speed, spontaneous, soft with moderate loudness. Patients spoken language can be generally understood.

Mood:

Patient is in euthymic mood.

Thoughts and Perception:

Thought process and content is coherent and appropriate respectively. There were no hallucinations, delusions or illusions.

Mental Status:

Using the Folstein Mini-Mental Status Exam, the patient scored 28 out of 30. In the classification, where a score 23-30 is normal, 19-23 is borderline, and (+) itching of left foot, (-) numbness, (-) changes in color of the extremities

O> 100/60--6718--36.8

Conscious, coherent, not in distress

Dirty sclerae, pink palpebral conjunctiva, no naso-aural discharge, no CLAD

Symmetric chest expansion, no retractions, clear breath sounds

AP, normal rate and regular rhythm

Flabby abdomen, soft, non-tender, normoactive bowel sounds

Full equal pulses, grossly normal

(+) multiple, well-defined erythematous plaques topped with crusting, ulceration and excoriation, distal aspect, medial left leg.

A> Mixed Wound Infection

DMT2, uncontrolled

P> DM diet, inc. OFI

For FBS, HbA1c, TC, TG, HDL, LDL, Creatinine

Meds:

1. Triderm cream BID

2. Cetirizine 10 mg BID BID for 5 days

3. Metformin 500 mg BID

For vaccination c/o Baluarte HC:

a. Pneumococcal

b. Hepatitis B

c. Influenza

Exercise at least 1 hour per day

Foot care and hygiene

Advised consult to an Ophthalmologist for evaluation and management of his blurring of vision

Advised regular check-up to health-care provider for his DM

Advised

Genoveva

56/F

S> patient had no subjective complaints except for cloudy vision on her right eye, previously diagnosed as Immature Cataract, OD (Manila Doctors Hospital, 2012). Non-smoker, non-alcoholic beverage drinker. No history of familial disease. (+) menopause at the age of 44. No history of gynecologic problems.

O> 120/80 78 18 37.0 C

Conscious, coherent, not in distress

Dirty sclerae, pink palpebral conjunctiva, no naso-aural discharge, no CLAD

Symmetric chest expansion, no retractions, clear breath sounds

AP, normal rate and regular rhythm

Flabby abdomen, soft, non-tender, normoactive bowel sounds

Full equal pulses, grossly normal

A> Essentially normal PE at the time of examination

Immature Cataract, OD

P> advised low salt, low fat diet to prevent development of Hypertension

Adequate fluid intake

Advised daily exercise

Medications:

1. Multivitamins + Ferrous Sulfate capsule, OD

Advised consultation to an ophthalmologist for evaluation and management of cataract

Well advised

Ryan

33/M

Not seen at the time of interview

Raymark

19/M

Not seen at the time of interview

Marjean

11/F

Not seen at the time of interview

Family Wellness Plan:

PRIMARY PREVENTION

SECONDARY PREVENTION

TERTIARY PREVENTION

Lamberto, 60/M

Regular exercise

Annual physical examination

Hepatitis B, Pneumococcal and Influenza vaccines

Vitamin supplementation

Personal hygiene

Dental hygiene

Health Education (Balanced at appropriate diet, accident exposure, polypharmacy)

Accident prevention

Annual BP monitoring

Annual fecalysis with occult blood testing

Annual urinalysis

Annual lipid profile determination

Annual Creatinine and GFR determination

Height and weight check (BMI)

Annual Audiometric Exam

DM diet

For FBS every 2-4 weeks until blood sugar is controlled; for HbA1c every 3-6 months

Triamcinolone cream BID to affected area

Cetirizine 10 mg BID for 5 days

Metformin 500 mg BID

Refer to Department of Ophthalmology for further evaluation and comanagement of the blurring of vision

Genoveva, 58/F

Annual Physical Examination

Regular age-appropriate exercise

Hepatitis B, Pneumococcal and Influenza vaccines

Vitamin supplementation

Personal hygiene

Dental hygiene

Health Education (Balanced at appropriate diet [DM diet], accident exposure, polypharmacy)

Accident prevention

Annual BP monitoring

Annual FBS, Lipid Profile determination

Annual Eye check-up

Height and weight check (BMI)

Annual Audiometric Exam

Annual Fecalysis and Occult Blood

Annual Chest X-ray

Annual breast examination

Annual Pap Smear and Pelvic Exam

N/A

Ryan, 33/M

Dental hygiene and monitoring

Education on proper hygiene: bathing every day, nail care, hand washing, family planning

Assessment and advise to quit smoking, consume alcoholic drink moderately

Advise to practice safe sex

Promote healthy lifestyle and diet

Weight monitoring

Address concerns about marital and family relationships

Advise proper use of OTC medications

Health education: Sanitation issues, consumption of junk food, accident prevention, sexual issues and health risks

BP monitoring annually

Fecalysis and urinalysis may be done annually

CXR annually

Annual PE should be done

During times of illness, advise to seek consult immediately and encourage family participation

N/A

Raymark, 19/M

Dental hygiene and monitoring

Education on proper hygiene: bathing every day, nail care, hand washing, family planning

Assessment and advise to quit smoking, consume alcoholic drink modetately

Advise to practice safe sex

Promote healthy lifestyle and diet

Sexual development and nutrition monitoring

Address concerns about peer pressure, parental relationship and courtship

Advise proper use of OTC medications and possible drug allergies

Health education: Sanitation issues, consumption of junk food, accident prevention, sexual issues and health risks

BP monitoring annually

Hearing acuity done atleast once

PPD may be done as screening for PTB

Fecalysis and urinalysis may be done annually

CXR annually

Annual PE should be done

During times of illness, advise to seek consult immediately and encourage family participation

N/A

Marjean, 11/F

Dental hygiene and monitoring

Education on proper hygiene: bathing every day, nail care, hand washing

Immunization based on EPI

Assessment and advise about accident exposure

Promote healthy lifestyle and diet

Motor development and nutrition monitoring

Address learning difficulties and language skills

Address concerns about moral and emotional development

Vitamin supplementation and assess drug allergies

Health education: Sanitation issues, consumption of junk food, accident prevention, sexual issues and health risks

BP monitoring annually

Teach breastself examination at age 9

Hearing acuity done atleast once

Visual acuity determination starting at age 9, done annually

PPD/ BCG direct may be done as screening for PTB

Fecalysis and urinalysis may be done annually

Annual PE should be done

During times of illness, advise to seek consult immediately and encourage family participation

How to get there?

Patients Household is found by passing 3 houses

along this street

Mrs. Genoveva Austria

The index patient, Lamberto Sr. with his grandchild, Marjean

With the interviewers

1954

Birth of Lamberto (Index patient)

1973

Lamberto and Genoveva got married, started to live together in Intramuros, Manila

1974

Birth of Gina, their first born via NSD

1975

1977

Birth of Teresa via NSD

Birth of Ryan via NSD

1979

Birth of Irene via NSD

1980

Birth of Raul ; Lamberto started to open food stall and sari sari store

1983

Birth of Joana via NSD

1985

Birth of Jennifer via NSD

1986

Birth of Lamberto Jr. via NSD

1988

Birth of Jacqueline via NSD

1991

Gina married Reynaldo and moved to Mindoro

1993

Birth of Rommel via NSD

1995

Birth of their 11th child, Raymark via NSD

1997

Teresa married Orlando and moved to Pangasinan

2011

Jacqueline married Alvin and transferred to Tondo

2012

Lamberto was diagnosed to have DM type 2

2013

Joana married Reynaldo