Family Case Presentation
University of the Philippines – Philippine General Hospital
Department of Family and Community Medicine
Payumo, Pelayo, Quiogue, Rodriguez
Specific Objectives
To formulate, implement, and discuss a patientcentered health management plan.
To describe the family psychodynamics using
widely used family assessment tools.
To discuss the social environment, its resources,
and hindrances to a successful wellness plan
To be able to formulate family wellness plans
To critically appraise a related journal article
and show its application to the case/community
Outline
I.
II.
III.
IV.
Index Case Profile
The Family
Family Wellness Plan
Journal
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Editha Abanilla
40 y.o./female
Single
Right-handed
Roman Catholic
Unemployed
Balacbacan, Laiya Aplaya,
San Juan, Batangas
Uncontrolled
Blood
Pressure
Occasional
Headache
Left Upper
Extremity
Numbness
Consult
Private MD
in Batangas
Work ups
Done
Amlodipine
(Norvasc) 5
mg OD
Metoprolol
(Neobloc) 50
mg BID
Weight Loss
Easy Fatigability
Heat Intolerance &
sweating
Difficulty Falling Asleep
Dysphagia
Palpitations
Consult at
Capitol
Medical
Center
Work ups
Done
RAI x 1 dose
Levothyroxine
(Thyrax) 150
mcg OD
Amlodipine
(Norvasc) 5
mg OD
Metoprolol
(Neobloc) 50
mg BID
Compliance
?
Regular
Follow up
Levothyroxine
(Thyrax) 150
mcg OD
ASYMPTOMATIC
Last follow
up was on
January
2009
Amlodipine
(Norvasc) 5
mg OD
Metoprolol
(Neobloc) 50
mg BID
ASYMPTOMATIC
Levothyroxine
(Thyrax) 150
mcg OD
Compliance
?
Usual BP = 140/90
Highest BP = 160/100
•
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•
•
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General: no weight loss, (+) weight gain, undocumented (about 30% in 2 years) no
loss of appetite, no fever, no night sweats
Skin: No rash, no lumps, no dryness, no pruritus, no changes in hair or nails
HEENT: occasional diffuse headache esp during hot weather, no dizziness, blurring
of vision, no tinnitus, no dysphagia, no gum/nose bleeding
Respiratory: no hemoptysis, no cough, no colds, no dypnea
Cardiovascular: no chest pain, no palpitations, no orthopnea, no easy fatigability,
no PND
GIT: no abdominal pain, no nausea, no vomiting, no diarrhea, no constipation, no
melena, no hematochezia
GUT: no dysuria, no oliguria, no hematuria, no urinary frequency
Hema: no excessive bleeding, no easy bruisability
Endocrine: no polyuria, no polyphagia, no polydipsia, no heat or cold intolerance,
no excessive sweating
MSS: no myalgia, no arthralgia
Neuro: no seizures, no loss of consciousness, no paresthesias, no paralysis
•
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•
(+) DM – Father, sister
(+) Heart Disease – Mother
(+) CVD – Sister
(+) HPN – Sister
(-) PTB
(-) Bronchial Asthma
(-) liver/kidney problem
• Menarche at 13 yrs old
• Regular Monthly Period, lasting for 3 days, use
of 3-4 ppd moderately soaked
• Occasional dysmenorrhea
• No previous sexual contact
• G0
•
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High school graduate
Nonsmoker
Nonalcoholic beverage drinker
Denies illicit drug use
Lives with brother and niece
Unemployed, supported by a brother who
works abroad
• Diet consists mostly of vegetables
• General: Conscious, coherent, not in cardiorespiratory distress
• BP: 140/80
HR: 66
RR: 18
Temp: 36.7
Wt: 78 kg
Ht: 157 cm
BMI: 31.6
• Skin: good skin turgor, no pallor, no cyanosis
• HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural
discharge, no tonsillopharyngeal congestion, no palpable cervical
lymphadenopathy, distended neck veins, no thyromegaly
• CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear
breath sounds
• HEART: adynamic precordium, normal rate, regular rhythm, apex beat at
the 5th ICS, LMCL, S1>S2 at the apex, S2>S1 at the base, no murmur
• ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, no
organomegaly
• EXTREMITIES: no edema, no cyanosis, full & equal pulses
• Awake, oriented to time, person and place
• Cranial Nerves:
CN I – can smell
CN II – (+) ROR, OU
CN III, IV, VI – EOM intact
CN V – bicorneal reflex intact
CN VII – no facial asymmetry
5/5
5/5
CN VIII – can hear
CN IX, X – gag intact
CN XI – good shoulder shrug
CN XII – tongue midline
5/5
100%
100%
++
++
5/5
100%
100%
++
++
MOTOR
SENSORY
DTR
• Hypertension Stage II, Uncontrolled
• Obese Class I
• S/P RAI ablation x hyperthyroidism
• Dianostics
– FBS, Urinalysis, Serum Crea, K, Lipid Profile, 12 L
ECG
– TSH
• Therapeutics
– Shift to Losartan + HCTZ 50/12.5 1 tab OD
– Cont Levothyroxine 150 mcg 1 tab OD
• Non-pharmacologic
– Low fat, low salt diet
– Daily exercise (brisk walking 30 mins OD)
– BP Diary
• Advised follow up to PMD
• Advised Ophtha Consult
FAMILY
ASSESSMENT
Outline
I. Family structure and function
•Genogram
•Type of Family
•Family Identification
•Stage in the Family Life Cycle
•Timeline
II. Family Psychodynamics
•Mapping
•Family Psychosocial Data
•APGAR
•SCREEM
ABANILLA-SIGANAY FAMILY
JULY 2009
ABANILLA
ALFREDO, 65
(1993)
SIGANAY
CRISCENCIA,
73 (2003)
4
PACIFICO
64
4
MERLYN
62
ANGELITO
56
2
3
3 Siblings
SUSAN
46
EDITH CHITO
38
40
JERRY
35
3
KIM
13
Diabetes Mellitus
Hypertension
Heart Disease
Mild Stroke
VANGIE
41
Type of Family
• Structure: extended-family
• Ordinal position: third to the last
child
• Family socio-economic class
patterns: middle-class
• Family set-up: democratic
Family Identification
• Composition
– Ate Edith: third to the youngest of
10 children
Family Identification
• Composition
– Kuya Chito: second to the youngest
in the family
Family Identification
• Composition
– Kuya Jerry: youngest child of
Abanilla family, currently in Canada
– Kim: 13-year-old daughter of Kuya
Chito
Family Identification
• Abanilla home has
– one bedroom
– a living-room with television and
stereo component
– a dining area with one table,
– a kitchen and a sink
– a dirty kitchen outside with 2
chained dogs named Santino and
Ampon
Social History
• Ate Edith graduated from Laiya
National High School. She worked for
3 years in a fruit store in San Pablo.
She then transferred to a grocery in
Poblacion for 1 year before staying in
Laiya with her brother Jerry and their
niece Kim.
• Prior to owning a resort, they had a
fishing business for 10 years. Ate
Edith now busies herself with the
resort and with collecting money for
electricity.
Social History
• Kuya Jerry is an HRM graduate who
later studied Culinary arts. He
financed his studies by having his
own catering business. He has
lived with his sister Edith but has
recently left to work in Canada as a
chef.
• He was the one who started plans
of owning a resort and now is its
main financier.
Social History
• Kuya Chito finished 3rd year HS,
after which he worked as a waiter
in Super Ferry for 3 years. It was
where he met his wife, who was
then his supervisor.
• He later transferred to work at
Kabayan resort in Laiya. He was an
employee there for 10 years and
recently was assigned at Kaffe
Brako as a barista.
Social History
• Kim is a 2nd year HS student. She
has stayed with Ate Edith and Kuya
Jerry since she was a child. Her
father has lived with them for 6
years now. Her mother works as a
supervisor in a Makro store in
Dubai; she goes home every 3
years.
Community
Neighborhood
• Sitio Balacbacan in Laiya Aplaya is home
to a number of beach resorts, composed
of several houses owned by common
families.
• Fishing is the community’s main
livelihood. Early morning each day,
fishermen bring ashore their catch for
the sitio’s consumption. As such,
everyday meals usually consist of fishbased viands.
• A recent issue of land ownership in
Balacbacan threatens its residents’
homes and livelihood.
Community
Neighborhood
• Balacbacan Residents
– They are usually composed of
each one’s relatives, although they
remain in good terms with the few
people who are not related to
them.
– They are hospitable and friendly,
and are used to having visitors and
tourists in their community.
Family Life Line
1992: Death of Ate Edith’s Father
2000: Kim’s mother left
2003: Death of Ate Edith’s Mother
2005: Island Sky Resort
2007: Relocation of People in
Balacbacan
June 2009: Kuya Jerry left for
Canada
Family Life Cycle Stage
• Since the three siblings share a home
with Kuya Jerry’s 13-year-old daughter
for the past few years, they can be said
to be in the stage of transition from
families with young children to families
with teenagers/ adolescents.
– For Ate Edith and Kuya Jerry, they had
adjusted their role as siblings to a role of
parenting as help to their brother Kuya
Chito. They shared with him the task of
child rearing, in addition to financial and
household tasks.
Family Life Cycle Stage
– With Kim now developing as a teenager,
the siblings must learn to be flexible
regarding understanding certain changes
in her. Although physical independence
is not yet an issue, psychological
independence may now be budding. Sex
education should also be given
importance, as early pregnancy in not
uncommon in Laiya.
– Ate Edith may also be dealing with
career issues, with the current threat of
land ownership in Balacbacan.
Family Life Cycle Stage
• The Abanilla family had faced their
parents’ death earlier in the cycle.
Thus, their concern is concentrated
to their generation and the
younger ones.
• Chronic illness, i.e., hypertension,
has also become a challenge to Ate
Edith, again earlier than expected
in the cycle.
FAMILY
PSYCHODYNAMICS
ABANILLA-SIGANAY FAMILY
JULY 2009
ABANILLA
ALFREDO, 65
(1993)
SIGANAY
CRISCENCIA,
73 (2003)
4
PACIFICO
64
4
MERLYN
62
2
ANGELITO
56
3
3 Siblings
SUSAN
46
EDITH CHITO
38
40
JERRY
35
3
KIM
13
VANGIE
41
Family Dynamics
• The Abanilla family is functional.
– The Abanilla siblings meet on special
occasions at Ate Edith’s house in Balacbacan.
– The family faced great challenges upon the
death of their father, followed years after by
the death of their mother. Their eldest
sibling became their leader and they coped
with death as a family.
– Ate Edith’s home is now composed of her,
Kuya Chito and his daughter Kim, and Kuya
Jerry. They have a good relationship and
currently have no source of conflict.
Psychosocial Data
• Communication patterns
– The Abanilla family’s communication
style can be said to be receptive,
occasionally with some distancing.
• The siblings’ separate family lives
sometimes make it difficult for them to
ask/give help from/to each other.
– Ate Edith’s home in Balacbacan is
more of the receptive type, as Kuya
Jerry finds time to regularly talk to
them although he is currently in
Canada.
Psychosocial Data
• Leadership
– This role belongs to the family’s
eldest, Kuya Pacifico.
• Age is a factor here.
• It was their Kuya Pacifico who helped
the family cope with their parents’
death.
Psychosocial Data
• Breadwinner
– This role is shared by Ate Edith,
who manages their resort, and
Kuya Jerry, who now works in
Canada as a chef. They also help
with financing Kim’s studies.
Psychosocial Data
• Authority
– According to Ate Edith, authority is
conferred mainly on Kuya Jerry.
Psychosocial Data
• Primary caregiver
– Ate Edith is the main care-giver of
the family since the wife of Kuya
Chito is abroad
Psychosocial Data
• Family’s present priorities
– Maintenance of the resort and their
corresponding land ownership is
the family’s main priority, especially
with the current issue in Balacbacan
regarding property rights.
FAMILY
APGAR
• Ate Edith
Family APGAR I
Palagi
A
Ako ay nasisiyahan dahil nakakaasa ako ng tulong sa aking
pamilya sa oras ng problema.
P
Ako ay nasisiyahan sa paraang pakikipagtalakayan sa akin
ng aking pamilya tungkol sa aking problema.

G
Ako ay nasisiyahan at ang aking pamilya ay tinatanggap at
sinusuportahan ang aking mga nais gawin patungo sa
bagong landas para sa aking ikauunlad.

A
Ako ay nasisiyahan sa paraang ipinadarama ng aking
pamilya ang kanilang pagmamahal at nauunawaan nila
ang aking damdamin katulad ng galit, lungkot, at pag-ibig.

R
Ako ay nasisiyahan at ang aking pamilya at ako ay
nagkakaroon ng panahon sa isa’t-isa.

Paminsanminsan
Halos Hindi

total: 9
Family APGAR I
• Kuya Chito
Palagi
A
Ako ay nasisiyahan dahil nakakaasa ako ng tulong sa aking
pamilya sa oras ng problema.
P
Ako ay nasisiyahan sa paraang pakikipagtalakayan sa akin
ng aking pamilya tungkol sa aking problema.

G
Ako ay nasisiyahan at ang aking pamilya ay tinatanggap at
sinusuportahan ang aking mga nais gawin patungo sa
bagong landas para sa aking ikauunlad.

A
Ako ay nasisiyahan sa paraang ipinadarama ng aking
pamilya ang kanilang pagmamahal at nauunawaan nila
ang aking damdamin katulad ng galit, lungkot, at pag-ibig.

R
Ako ay nasisiyahan at ang aking pamilya at ako ay
nagkakaroon ng panahon sa isa’t-isa.

Paminsanminsan
Halos Hindi

total: 9
• Kim
Family APGAR I
Palagi
A
Ako ay nasisiyahan dahil nakakaasa ako ng tulong sa aking
pamilya sa oras ng problema.

P
Ako ay nasisiyahan sa paraang pakikipagtalakayan sa akin
ng aking pamilya tungkol sa aking problema.

G
Ako ay nasisiyahan at ang aking pamilya ay tinatanggap at
sinusuportahan ang aking mga nais gawin patungo sa
bagong landas para sa aking ikauunlad.

A
Ako ay nasisiyahan sa paraang ipinadarama ng aking
pamilya ang kanilang pagmamahal at nauunawaan nila
ang aking damdamin katulad ng galit, lungkot, at pag-ibig.

R
Ako ay nasisiyahan at ang aking pamilya at ako ay
nagkakaroon ng panahon sa isa’t-isa.

Paminsanminsan
Halos Hindi
total: 10
Family APGAR II
Source: Ate Edith
Who lives in your home?
How do you get along?
Name
Chito
Relationship
Brother
Age
38
Sex
M
Kim
Niece
13
F
Well Fairly Poor


SCREEM
Resource
Social • Well-balanced lines of communication with other
members of the community
• Ate Edith is the main electricity collector in
Balacbacan.
• Ate Edith usually spends time in the afternoon in
her brother’s house. She lives in a neighborhood full
of their relatives.
• Ate Edith loves watching television especially
telenovelas.
• Ate Edith sometimes plays badminton with her
niece in their backyard.
Pathology
---
Resource
Social • Kuya Chito has a set of good friends in Site
with whom he spends time.
• Kim likes spending time with her best friend,
Vanessa. Kim usually spends her time studying
during weekdays and watches the television
during weekends.
• Each member of the family is free to pursue
on his/her chosen activities
Pathology
---
Resource
Cultural • The Abanilla family are proud Batanguenos.
• They are proud of the beach and the
beautiful mountains in Aplaya.
• They said that Batanguenos are “mababait”.
• Offer us fish like tamban, and Ate Edith’s
homemade dried fish
• Taught us Batangueno terms iibong-ibong
Pathology
---
Resource
Religious • Non–practicing Roman Catholic
Pathology
Does not
observe the
• They attend mass during Sundays only about Lenten season
twice as year
(because it is
the resort’s
• Celebrates All Saints day, Christmas and
peak season)
other Holidays. Observe “pasiyam” and prayer
for the dead on the 40th day of burial
• No rigid religious rituals and seem to be
open to new ideas
Resource
Economic • Main source of income is Kuya Jerry
who is working abroad (Canada)
• Economically stable and seems to have
no financial difficulties
• Kuya Chito also earns enough for him
and Kim and his wife works in Dubai to
pay for Kim’s schooling.
Pathology
Resource
Economic • Ate Edith is satisfied with present
economic condition; “Hindi kami
nagigipit at may sobra pa nga.”
Pathology
Resource
Educational • Ate Edith – high school graduate
• Kuya Chito – finished up to 3rd year high
school
• Kim is presently on her 2nd year high
school and plans to pursue a degree in
college
Pathology
---
Resource
Educational • Members of the family had adequate
education such that most of the
problems encountered were settled
satisfactorily.
• Not burdened by inadequate
educational attainment
• Ate Edith and Kuya Chito have no plans
to pursue their studies again.
Pathology
---
Resource
Medical
• The Abanilla family has a good
health seeking behavior.
• Health care is easily available
since the barangay health center is
just a walk away and the BHWs are
familiar to them, especially that
they have relatives who are BHWS.
• Ate Edith goes to Poblacion or
Capitol for her medical check –up.
Pathology
Resource
Medical
• Kuya Chito and Kim rarely get sick.
Pathology
Family Wellness Plan
Edith Abanilla, 40 year old
• Screening
– Daily personal hygiene
– Daily BP monitoring
– Monthly self breast examination
and annual by MD
– Biannual dental hygiene
– Annual periodic physical exam
– Annual fecalysis, urinalysis, CXR,
cholesterol monitoring
Edith Abanilla
• Developmental monitoring
– Obesity and pre-menopausal
counseling
– Mental health
– Family relationship
– OTC for common ailments
– Sanitation issues, accident
exposure and prevention
Edith Abanilla
Exercise Prescription
• Frequency: 3-4x per week
• Intensity:
Target Heart Rate: (220-40)x activity
=(220-40)x 0.6
=108 beats/min
• Duration: 30 minutes/session
• Type: Walking exercises
• Time: Approximately 1.5 hours per week
Edith Abanilla
Diet Prescription
• Daily Caloric Requirements= DBW x activity
DBW=(height in cm-100) – 10%
= (157-100) – 5.7
=51.3 kg
Edith Abanilla
Diet Prescription
• Total Caloric Requirements= 51.3 kg x 25=
cal/day
= 1282.5
cal/day
• Carbohydrates = 1282.5 x 0.6= 769.5 cal/4=
192.38 grams
• CHON = 1282.5 x .25 = 320.625 cal/4= 80.156
grams
• Fats = 1282.5 x .15 = 192.375cal/9 = 21.375
grams
ACTUAL BODY WEIGHT – 78 kg
Edith Abanilla
• Stress
– Maintenance of resort and land
dispute
– In-charge of collecting electrical
fees of people in Balacbacan
– Taking care of Kim and her studies
Chito Abanilla, 38 year old
• Screening
– Daily personal hygiene
– Annual BP monitoring
– Biannual dental hygiene
– Annual periodic physical exam
– Annual fecalysis, urinalysis, CXR
– Reduce alcohol intake into
moderation: 1 glass/day; smoking
cessation
Chito Abanilla
• Developmental monitoring
– Weight counseling
– Mental health
– Family, marital relationship
– OTC for common ailments
– Sanitation issues, accident exposure
and prevention
Chito Abanilla
Exercise Prescription
• Frequency: 3-4x per week
• Intensity:
Target Heart Rate: (220-38)x activity
=(220-38)x 0.6
=109 beats/min
• Duration: 30 minutes/session
• Type: Walking exercises
• Time: Approximately 1.5 hours per week
Chito Abanilla
Diet prescription
• Daily Caloric Requirements= DBW x activity
DBW=(height in cm-100) – 10%
= (167.64-100) – 6.76
=60.88 kg
Chito Abanilla
Diet Prescription
• Total Caloric Requirements= 60.88 kg x 25=
1522 cal/day
• Carbohydrates = 1522 x 0.6= 913.2 cal/4=
228.3 grams
• CHON = 1522 x .25 = 380.5 cal/4= 95.125
grams
• Fats = 1522 x .15 = 228.3 cal/9 = 25.37 grams
ACTUAL BODY WEIGHT – 68 kg
Chito Abanilla
• Stress
– Being far away from his wife
– Raising a teenage daughter
Kim Abanilla, 13 year old
• Screening
– Daily personal hygiene
– Annual BP monitoring
– Monthly self breast examination
– Annual periodic physical exam
– For hearing test
– Annual fecalysis, urinalysis,
PPD/Direct BCG
Kim Abanilla
• Developmental Monitoring
– Growth Chart and Nutrition
– Sexual Development
– Emotional and Mental Development
– Parental relationship
– OTC for common ailments
– Sanitation issues and accident
exposure
Kim Abanilla
Exercise Prescription
• Frequency: 3-5x per week
• Intensity:
Target Heart Rate: (220-13)x activity
=(220-13)x 0.6
=124 beats/min
• Duration: 30 minutes/session
• Type: Cardiovascular and muscle
strengthening/toning exercises
• Time: Approximately 2 hours per week
Kim Abanilla
Diet Prescription
• Daily Caloric Requirements= DBW x activity
•
DBW=(height in cm-100) – 10%
•
= (157-100) – 5.7
•
=51.3 kg
• Total Caloric Requirements = 51.3kg x 35 =
1795.5 cal/day
• Carbohydrates = 2047.5 x 0.6= 1077.3 cal/4 =
269.32 grams
• CHON = 1795.5 x .25 = 448.875 cal/4 =
112.22 grams
• Fats = 1795.5 x .15 = 269.325 cal/9 = 29.93
grams
• Actual Body Weight – 46 kg
Kim Abanilla
Stress
• Being far away from her mother
• Being in high school
JOURNAL APPRAISAL
THANK U!