a family case presentation
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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
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