Family Case1

8/16/2019 Family Case1

1/51

University of Perpetual Help

Dr. Jose G. Tamayo Medical Center Sto. Niño, Biñan, Laguna

Department of Family and Community Medicine

Family Case

May 20, 2016

Janel Enriquez

Weshley Manarin

Charles Lao


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• The house

– Semi concrete house

– 1 bedroom

– 1 comfort room

– Livin room

– ! electric fan – 1 T"

– #inin room

– $ %indo%s

– 1 as stove


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• o&en drainane

• 'ood ventilation

• Toilet( )ushed toilet

• 'arbae dis&osal( daily

collection

• Water source( launa%ater * distilled %ater


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• Lives %ith husband+

son and his family

• Easy access %ith the

neihborhood and

&ublic trans&ortation


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FAMILY STRUCTURE• Structure:

,nilaterally E-tended family

• Family socio-economic class patterns:Middle.class

• Family set-up:#emocratic


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FAMILY LIFE CYCLE

Family in Later /ears


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PSYCHOSOCIAL DATA

0read%inner

rimaryCareiver

Juanito

John

2nnaliza

Leader


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GENERAL DATA

M323 4 female4 Married

5oman Catholic

Fili&ino

6ctober 17+ 8ovember+ $+

179:am&ana

0i;an+ Launa


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CHIEF COMPLAINT

=

Right lg !ai"


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HISTORY OF PRESENT ILLNESS

• ?@A riht arm %eaBness

• ?@A riht le &ain+ squeezin+ non radiatin+41> • 8o medications taBen+ no consult done3

1 %eeB TC


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• Sym&toms &ersisted

• Massaed riht le %ith unrecalled ty&e ofherbal oil

• 2Dorded tem&orary relief

• 8o associated sym&toms such as numbness+limitation of movement nor %eaBness3

•

8o medications taBen+ no consult done3

days TC


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• ?@A riht le &ain &ersisted+ !41> &ainscale

• Souht consult in this institution for furtherevaluation and manaement

Fe% hours TC


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PAST MEDICAL HISTORY

• ?@A #M $ years old – 'licazide 9>m4tab com&liant

• ?@A hy&ertension :$ years old – Clo&idorel 0isulfate

– Tremazitide

– "itamin 0 com&le-

• ?@A os&italization y&ertension

? increase 0 !>>41>>A• ?.A 2llery to drus


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FAMILY HISTORY

• ?@A y&ertension aternal• ?@A C"2 0oth

• ?@A T0 Maternal


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FAMILYASSESSMENT


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FAMILY GENOGRAM

LE'E8#(

.#M.Cancer4Colon

. y&ertension

2LC2G25 F2M1:

2ido+ H! y4oSecundina+ I! y4o Cuenco+ Ca&ili

2doracion I>

Juanito HI

Felito HEster+ H$Carmela+ :2morel+ Lebrada :IEvanelita+ I9Lotardo+ I9

Mercedita + H7

#on+ :2uusto+ :>

Jonathan+ 9 John+ $I 2nnaliza+ $I Jose+ $

8athaniel+ !9 atricB+ !1 abella+ 17

June 9 + 17:!


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FAMILY APGAR#Da$ght%&i"&la'(

2'25 K,ESTA

2#2T2T


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FAMILY APGAR#H$)*a"+(

2'25 K,ESTA2#2T2T


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FAMILY APGAR#Pati"t(

2'25 K,ESTA2#2T2T


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FAMILY SCREEMSC5EEM 5ES6,5CES 2T6L6'/

S6C


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TraNectory of


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Family in FunctionalEquilibrium

ST5ESSF,L L


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PERSONAL AND SOCIAL HISTORY

• ?.A revious smoBer(• ?.A revious alcoholic drinBer


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REIE3 OF SYSTEMSNEUROLOGIC N ha+a/h, " )i4$%)

S


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PHYSICAL E5AMINATION'E8E52L S,5"E/

2%aBe+ conscious+ coherent+ not in cardiovascular distress

"


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NEUROLOGIC E5AMINATIONCERERUM 6riented to &erson+ &lace and

time

CEREELLUM 8o nystamus

CN I Can smell

CN II !.9mm+ equally reactive to liht

CN III,I, I >=

1>>=

1>>=

1>>=

@@

@@

@@

@@


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FAMILY 3ELLNESSPLAN


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Mercedita+ H74F

• Screenin• 0( annual

• 2nnual cholesterol+ fbs+ bun+ creatinine+ uric acid

• "isual acuity( annual * eye &ressure screen forcataract at > on%ards

• earin( de&end on %orB e-&osure

• 0reast e-am( self breast a* M# e-am reularly

• 288,2L( &a&smear +#5E+ F60T+ F2+ ,2+ CR5+ E

• yiene( dental+ bathin+ nails+ hand%ash


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Mercedita+ H74F

• Screenin• ealth behavior( smoBin+ alcohol+ se- life+

caDeine+ occu&ational hazard+ accident

•


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• #evelo&mental monitorin

• /S


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Juanito+ HI4M• Screenin• 0( annual




• 288,2L( #5E+ F60T+ F2+ ,2+ CR5+ E



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Juanito+ H74F• Screenin

• ealth behavior( smoBin+ alcohol+ caDeine+occu&ational hazard+ accident

•


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• /S


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John+ $94M• Screenin• 0( annual




• Family &lannin

• 288,2L( #5E+ F60T+ F2+ ,2+ CR5+ E



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John $94M• Screenin

• ealth behavior( smoBin+ alcohol+ se- life+caDeine+ occu&ational hazard+ accident

•


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• /S


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2nnaliza+ $!4F





• 0reast e-am( self breast a* M# e-am reularly

• 288,2L( &a&smear +#5E+ F60T+ F2+ ,2+ CR5+ E


• Family &lannin


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2nnaliza+ $!4F



•


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• /S


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8athaniel+ !94F


• 2nnual cholesterol+ fbs

• "isual acuity( annual


• 288,2L( F2+ ,2+ CR5+ E



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•


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• /S


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atricB+ !14M• Screenin• 0( annual




• 288,2L( F2+ ,2+ CR5+ E



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•


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• /S


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abella+ 174F• Screenin• 0( annual




• 288,2L( F2+ ,2+ CR5+ E



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•


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• /S


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Fi"al Diag")i) Ty&e of family( ,nilaterally e-tended

Family 2'25( ihly functional family

Family SC5EEM(

Family has adequate resources to co&e %ith

crisis

Stae of Family Life Cycle( Family in later years

TraNectory of


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Fi"al Diag")i)

• 0iomedical #ianosis(

6steoarthritis+ 8


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• Stae

Family Case1

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