TABLE OF CONTENTS

Curriculum Vitae ......................................................................... 3

EXPECTATIONS IN COMMUNITY AND FAMILY MEDICINE ......... 4

CLINICAL HISTORY ....................................................................... 5

SAMPLE ENDORSEMENT ............................................................. 8

FAMILY CASE (ORANGE SERVICE) ............................................. 12

In DCFM: A Reflection ............................................................... 24

DOCUMENTATION .................................................................... 25

2
 Curriculum Vitae
Manvar, Deepkumar P.
Swastik Society Jamnagar, Gujarat

PERSONAL INFORMATION
GENDER Male
BIRTHDATE 06/27/1997
PLACE OF BIRTH Gujarat, India
CIVIL STATUS Single
RELIGION Hindu
CITIZENSHIP Indian

EDUCATIONAL BACKGROUND
DOCTOR OF MEDICINE 2016-Present
Anticipated July 2020
University of Northern Philippines
Tamag, Vigan City, Ilocos Sur
BACHELOR OF SCIENCE IN 2014-2016
COMMUNITY HEALTH University of Northern Philippines
MANAGEMENT Tamag, Vigan City, Ilocos Sur
HIGHER SECONDARY SCHOOL 2012-2014
Prime Science School Gujarat,
India
SECONDARY SCHOOL 2009-2012
Shree Satya Sai Vidhyalaya,
Gujarat, India
PRIMARY SCHOOL 2002-2009
Shree Satya Sai Vidhyalaya,
Gujarat, India

3
 EXPECTATIONS IN COMMUNITY AND FAMILY MEDICINE

The following are my expectations in this rotation:

1. I will be able to independently and competently practice the principles of
community and family medicine
2. I will be able to be prepared to provide continuing, comprehensive and personal
care within the context of family and the needs of the community

3. Be able to provide care with a systems-based approach, while serving as a

patient advocate.

4. Be able to effectively communicate with the patient, family and healthcare team
about the diagnosis, evaluation and management of a particular condition in a
collaborative fashion.

6. Be competent in the care of patients throughout the continuum of life,

managing their care in multiple environments including but not limited to home,
office, acute care hospital and long-term care facilities.

7. Have the technical skill, knowledge and experience to perform clinical

procedures within the scope of family medicine reflecting the training, experience
and the needs of the community.

8. Demonstrate the ability to join or build a fiscally sound practice that meets the
identified needs of the community served utilizing the principles of the patient-
centered medical home.

9. Demonstrate knowledge and experience with understanding the public health

issues in their communities, and coordinate care with community health agencies
to improve the health of their patients and community

4
 CLINICAL HISTORY

Annalyn Rose Gutierrez, female, Catholic, 2 years and 6 months old, born on 20 th of March
2017 and presently living at Bauang, La Union. She was first admitted on September 26, 2019
in ITRMC together with her mother. Her mother was complaining that the child had been
experiencing cough (which is the chief complaint).

Informant: mother
Reliability: 96 %
Chief complaint: cough
History of present illness:
 6 days prior to admission the patient had
o dry cough with associated colds with clear nasal discharge
o with an undocumented on and off fever
o No vomiting, no diarrhea, good appetite on both solids and liquids, good
breastfeeding, able to play with no noted signs of respiratory distress.
o Paracetamol 250mg/5ml given every 4hours with afforded relief in fever.
o No consultation done.
 5 days prior to consult
o still with persistence of above cough (productive with white phelgm) and colds,
fever of 38.9-39 oc
o good appetite noted for both breakfast and lunch, good breastfeeding, able to
play with no signs of distress.
o At night, poor appetite with solid foods noted, still with good breastfeeding.
o Mother noted tachypnea hence nebulized with salbutamol-1neb with afforded
relief of tachypnea.
o Paracetamol 250mg/5ml, 2.5ml given every 4hours for continous fever.
o No consults.
 4 days prior to consult
o with on and off tachypnic episodes nebulize wth salbutamol 3 doses with afforded
temporary relief of tachypnea
o no consultation done.
 3 days prior to consult
o still with cough, colds and continuous fever, poor oral meals, good breastfeeding,
sleeps most of the time.
o Tachypnea with associated audible wheezing noted hence nebulized with
salbutamol 2 doses.
o No consultation done.
 2 days prior to consult
o still with wheezing and tachypnea hence consultation of the ambulatory er ,
salbutamol neb given-3 doses.
o Diagnosis at er-pediatric community acquired pneumonia-b.
5
 o Prescribed medication –
 paracetamol 250 mg/5ml , 3ml every 4 hours ,
 amoxicillin 250/5ml , 2.5ml every 8 hours for 7 days ,
 salbutamol neb every 6 hours for 3 days.
 1 day prior to consult
o still with cough and colds
o temperature range of 36.3- 37 oc sleeps most of the time
o with good breast feeding, but no appetite in eating solid foods.
o No vomiting, no LBM.
 Today the patient came to OPD for follow up, but due to persistence of symptoms,
o later the patient was admitted in DCFM ward.
o At opd, cxr done: bilateral pneumonia.
 Last febrile episode was 2pm on sept-25, 2019.
 Last dose paracetamol 4pm on 26sept
Laboratory workouts:
o Cbc done:
o wbc:9.6; n:72.2; l:24.4; m:3.3; e:0; b:0;
Past medical history: patient was diagnosed with clinical asthma on December 2018 at ITRMC
but no maintenance meds given. No past hospitalizations, no admissions, no allergy
Vaccination history:
BCG:3/2017 HEPB: 5/20/17
DPT-HEPB-HIB-3 doses given OPV: 3 doses given
IPV: given PCV: 3 doses given
MMR: given at 9mos and 1year

Personal and social history: 6 members in family

in 1 room. Pets-2 dogs.
Water for domestic purpose- pump well and Family history
nawasa. father: mother:
Drinking water-mineral. Garbage-segregated and (+)asthma (-)asthma
collected by MWF. (since birth)
(-) allergies, (-) allergies,
(- (-
)hypertension, )hypertension,
Review of system:
(-)diabetes (-)diabetes
General : (-)weight loss,(+)febrile episodes,(-)chills,(-)sweat,(-)irritability, good
suck, poor oral intake,(-)lethargy.
Integumentary :(-)cyanosis,(-)pallor,(-) jaundice, (-)lesion,(-)rash, (-) dry skin
head,eyes,ears,nose,throat(heent) :
Head:(-)history of head injury ,(-) headache
6
 Eyes:(-)blurringofvision,(-)pain,(-)redness,(-)spots,(-)specks,and(-)sunkeneyeballs.
Ears: (-) earaches, (-) discharges, normally aligned ears.
Nose: (-) cold, (-) nasal stuffiness, (-) discharge, (-) itching, (-) nosebleed, (+) smell
Mouth and throat: (-) bleeding of gums,(-)sore throat ,(-)ulcer, (-) hoarseness, (-) soreness
, (-) dental caries, (-) enlarging tonsils.
Neck: (-) swollen glands.(-) lumps, (-)pain and(-)stiffness of the neck.
Respiratory: (+) cough, (-)sputum,(-) haemoptysis,(-)dyspnea,
Cardiovascular: (-)cardiovascular disease.
Gastrointestinal: (-)vomiting, (-)diarrhea, (-) abdominal pain.(-)bleeding ,(-)jaundice.
Urinary: (-) oliguria,(-)urgency, (-) dysuria, (-)hematuria.
Genital :(-)discharge, (-) pain, (-) swelling, (-) itchiness
Musculoskeletal :(-)stiffness,(-)deformities,(-)tenderness,(-)swelling, (-) pain
Neurologic: (-)irritable,(-)seizures,(-)motor or sensory loss.
Extremities: (-)numbness
Physical examination:
General survey: awake, weak looking, irritable, not in cpd
Vital signs: bp:90/60 pr:128bpm ,rr:57bpm, t:38.3oc, spo2: 99% weight 45.11kg
Skin: no pallor, no jaundice, warm to touch, no cyanosis
Heent:
Head: no scar lesion, no gross deformities, or tenderness,
Eye: (-)edema, anicteric sclera, pink palpebral conjunctiva,(-)discharge
Ear: normal ears, (-)discharge, intact tm,
Nose: (-)discharge,(-)congestion
Mouth and pharynx: normal oral mucosa, (-)dry lips, (-)fissures on lips
Neck:(-) deformities, (-) lesions, (-) swelling, (-)clad, (-) tenderness.
Chest and lung: sce,(-)lagging,(-)retraction,(+)bilateral crackles,(-) wheezing, (+)subcostal and
intercostal retractions
Heart: adynamic precordium (-)thrills, (+)tachycardic (-)murmur, nrrr
Abdomen: (-)ruq tenderness, normoactive bowel sounds
Genitalia: not assessed
Extremities: hyperpigmented patches on both lower extremities, no pallor, no gross
deformities, (+) full and equal pulses, no edema, crt <2sec.
Neurologic examination :
Cerebrum: irritable but consolable
Cerebellum (-)tremors,(-)nystagmus,(-)ataxia
Cranial nerves :
Cn i : (+)smell
7
Cn ii : (+) see
Cn ii and cn iii: pupils equally reactive to light and positive accommodation.
Cn iii, iv, vi : intact eom
Cn v : (+)corneal reflex,(+) able to chew
Cn vii : symmetric nasolabial folds on smiling
Cn viii : normal hearing
Cn ix , x: uvula at midline,(+) gag reflex
Cn xi : able to shrug shoulder, able to move head from side to side.
Cn xii :able to protrude tongue,(-)deviation.
Babinski (-) kernigs sign (-)
Brudzinski sign (-) ankle clonus (-)

Motor : (appropriate for age) sensory : ( can feel objects) DTR

5/5 5/5 100 100 +2 +2
5/5 5/5 100 100 +2 +2

ADMITTING DIAGNOSIS: PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA-C

Diagnostic: CXR, CBC

PLAN: IVF D5imb 41-42cc/hr as maintenance ,
discontinue Amoxicillin
start Cefuroxime500mg TIV every 8hours,
Paracetamol 150mg TIV every 4hours if temp>37.8 oC,
N-acetylcysteine 200mg ODHS,
zinc sulfate 5mg/5ml OD.

SAMPLE ENDORSEMENT

ADMITTING VS: T ADMITTING IVF PNSS 1L X

PALLIATIVE WARD 36.8, HR 103, RR DIAGNOSIS: 10-
AA 119, BP 120/60, 15GTTS/HR
50/M/SINGLE SPO2 98%, WT ATOPIC DIET AS
San Agustin, San Fernando City, 52KG DERMATITIS VS
TOLERATED
La Union (CBHP Partner IRRITANT
VS Q4
Community) Cc: Generalized skin CONTACT
lesions DERMATITIS,
CIC: DR. CHUA-CHAN/RAFAEL SEVERE, WITH CURRENT MEDICATIONS
RIC: DR. HPI : SUPERIMPOSED 1. CETIRIZINE 10 MG/TAB
SORIANO/BUTAY/CARBONELL 2 months PTC, BACTERIAL 1 TABLET ODHS
patient noted an INFECTION 2. PETROLATUM
CCIC: MANVAR/ALUG erythematous TOPICAL, APPLY ON
pruritic lesion on
8
HD: 4 right shin, with R/O PSORIASIS, TRUNK AND
DOA: 09/21/2019 irregular borders and TINEA CORPORAL, EXTRIMITIES BID
DOB: 02/03/1969 associated plaques. SEVERE 3. CLEANSING BATH: 10
POA: DCFM-ER Noted progression to ML BLEACH TO 1
TOA: 09:30 AM left lower extremity PWI: GALLON OF WATER
and then to both ONCE A DAY FOR NOW
VS RANGE upper extremities ATOPIC 4. CO-AMOXICLAV
T : 36.7-37.2 after patient washed DERMATITIS 625MG/TAB. 1 TAB Q8.
HR :81-96 with paint thinner SEVERE, WITH 5. PREDNISONE 10
RR : 19-21 after a painting job. SUPERIMPOSED MG/TAB, 1 TAB 3 TIMES
BP 110-120/70-80 Size range of lesions BACTERIAL A DAY AFTER MEALS
SPO2 : 98-99 1 to 4 inches in INFECTION R/O FOR 5 MORE DAYS. (
diameter. PSORIASIS TOTAL OF 7 DAYS
TREATMENT WITH
CURRENT VS Patient consulted at ORAL STEROID).
T : 36.7 our barangay health
HR :87 center 2 weeks after PREVIOUS MEDICATIONS:
RR : 21 onset of symptoms 1.AMPICILLIN 2G IV Q6 –
BP : 120/80 with initial working D1 +1
SPO2 : 98 impression of Tinea 2. PREDNISONE 10
Pedis with MG/TAB 1 TABLET AFTER
INPUT :1400CC superimposed BREAKFAST, 2 TABLETS
OUTPUT: 1200CC bacterial infection AFTER LUNCH, 2
and was given TABLETS AFTER DINNER
Betamethasone +
Clotrimazole + IM DERMA NOTES:
Gentamicin ointment 1:PATIENT SEEN AND
with EXAMINED
recommendation to HX AND PE REVIEED
undergo skin DX: ALLERGIC CONTACT
scraping KOH. DERMATTIS
PLAN: CONTINUE
Patient noted non PRESENT MANAGEMENT
resolution of skin SUGGEST DECREASE
lesions with further PREDNISONE TO 25
progression and was GM/DAY IF OK WITH
advised to consult at MAIN SERVICE
ITRMC where he was BATH 2X TIMES A DAY
seen at the IM OPD. SUGGEST AND REPEAT
Skin KOH done but CBC
results were not SUGGEST TO SHIFT
known to patient. He ANTIBIOTIC TO CO-
was given Cetirizine AMOXICLAV 625 GM/CAP
and an unrecalled I CAP BID.
ointment. 2: SUGGEST TO TREAT PX
AS OPD
Patient was referred FOR FULL BATHING.
back to us by the PSORIASIS CANNOT
barangay officials TOTALLY RULE OUT
because lesions were

9
noted to further SUGGEST TO AVOID
progress and that SYSTEMIC STEROIDS.
patient has not been SUGGEST BATHING TWICE
going out of his A DAY
house for more than
a month and has FOR POSSIBLE MAY GO
recently been HOME TODAY IF REPEAT
refusing to eat. CBC IMPROVED AND
WITH CONTINOUS
House visit CLINICAL IMPROVEMENT.
conducted where
patient was noted PLAN:
lying on wooden AWATING CBCPC. 6 AM
bench with
generalized skin
lesion of white scales
with erythematous
base, distributed all
over body with
sparing of upper
face.

Patient was then

advised for
admission for
workup and possible
initiation of IV meds
as well as specialist
referral. Admission
was advised also
because patient was
presenting with
depressive
symptoms.

PROGRESS NOTES:

S: no pruritis, good
oral intake, no fever,
O: awake, alert, not
in CP Distress
(+) generalized dry,
scaly,
erythematous to
hyperpigmented
lesion all over the
body coalescing
into plaques, (+)
excoriations

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 anicteric sclera,
PPC, (-) CLAD
symmetrical chest
wall expansion, (-)
retractions,
Adynamic
precordium, NRRR,
(-) murmur
Globular, soft,
NABS, non-
distended, non-
tender
Full and equal
pulses, good skin
turgor, (-) edema,
CRT <2sec

PHQ-9: 5/9

CBC
DATE WBC Seg Lym Mono Eos Bas Hb Hct Plt MCV MCH MCHC
09/21/20
17.0 72.3 14.2 7.7 4.5 1.3 146 0.44 489 93.4 31.3 335
19

CLINICAL CHEMISTRY
DATE GLUCOSE ALT AST UREA/BUN CREA URIC ACID CBG
eGFR
09/02/20 24.0 U/L
19
09/21/20 18.6 U/L 2.45 mmol/L (1.70 – 117 0.562 113mg/dl
19 8.30)
09/22/20 5.22
19 mmol/L

KOH NO FUNGAL ELEMENT SEEN

9/21/20 WOUND GRAM NO GRAM-POITIVE AND GRAM-
19 STAIN NEGATIVE MICROORGANISM SEEN

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 FAMILY CASE (ORANGE SERVICE)
Clinical History
GENERAL DATA:
Flores Luvimi, 72 yr. old widow female, born on May 8, 1947, Roman Catholic, a farmer who
presently lives at Bauang, La union.
INFORMANT: Patient, with reliability of 95%.
CHIEF COMPLAINT: Body Weakness & Cough
HISTORY OF PRESENT ILLNESS:
 Patient is a known case of DM type 2 diagnosed last December 2014.

 2 weeks PTC, patient started to have cough, non- productive, usually more frequent
during bedtime and upon awakening, usually remedied by drinking water and rest. No
meds taken and no consult done. Not associated with difficulty of breathing, back
pain, chest pain, dizziness and vomiting.

 10 days PTC, symptoms persisted, still with cough which is non productive, more
frequent at bedtime and upon awakening, remedied by drinking water and rest. No
meds taken and no consult done. Associated with back pain, easy fatiguability, and
decreased appetite as claimed. No dizziness and vomiting.

 8 days PTC, still with non productive cough with the same severity, associated with
back pain, easy fatiguability, decreased appetite, dysuria, urinary frequency and
dizziness. Consulted at the OPD due to the scheduled follow-up check up for DM.
Patient was submitted for routine lab test which she complied the following day.

 6 days PTC, still with non productive cough and patient came in with the lab results
and UA is consistent with urinary tract infection thus patient was diagnosed and
managed as a case of acute complicated cystitis and was sent home with Ciprofloxacin
500mg/tab, 1 tab BID for 10 days as treatment.

 4 days PTC, still with non-productive cough, more frequent at bedtime and upon
awakening, associated with back pain, easy fatiguability, difficulty of breathing, back
pain, decreased appetite and undocumented febrile episode which occur in the late
afternoon. No meds taken for fever and cough and no consult done.

 4 days PTC, still with non-productive cough, more frequent at bedtime and upon
awakening, associated with back pain, easy fatiguability, difficulty of breathing, back

12
 pain, decreased appetite and undocumented febrile episode which occur in the late
afternoon. No meds taken for fever and cough and no consult done.

 1 day PTC, above signs and symptoms persisted accompanied with body weakness,
patient sought consult at OPD wherein chest X- ray and repeat urinalysis were done.
CBG (RBS) was done revealing 399mg/dL, was advised for admission but refused due
to unavailability of caregiver.

 Few hours PTC, persistence of non-productive cough, more frequent at bedtime and
upon awakening, associated with back pain, easy fatiguability, difficulty of breathing,
back pain, decreased appetite, dizziness and body weakness prompted patient to seek
consult at the OPD and was advised for in hospital management hence admitted.

 No known allergies to food and drugs.

 Maintenance medications include:

Metformin 500mg/tab, 1 tab TID
Rosuvastatin 20 mg/tab, 1 tab OD
Pregabalin 50mg/tab, 1 tab OD
Gliclazide 80mg/tab, 1 tab BID

PAST MEDICAL HISTORY:

 2014 - admitted at ITRMC for 5 days due to body malaise and dizziness, diagnosed
with type 2 DM, was sent home improved and with therapeutic regimen for DM and
was advised for follow up every after 3 months.
 2006 - admitted at ITRMC for 5 days, underwent cholecystectomy and was sent home
well.
 1987 - admitted at Lorma Medical Center for 7 days, underwent TAHBSO for
prophylactic
management for malignant ovarian tumor, and was sent home well.
FAMILY MEDICAL HISTORY:
(+) oesophageal cancer (mother)
(+) glaucoma (sister)
(-) asthma
(-) allergies
(-) CA
(+)colon cancer (husband)

OB GYNE HISTORY:
G7P7 (7006)
13
M - 14 years old
I - regular (30 days)
D - 5 to 7 days
A - 1 to 2 pads per day
S - no dysmenorrhea, no diarrhea and no dizziness
* Menopause at the age of 43 after the TAHBSO at 1987
* first child until the 5th child were all delivered at home, and the next 2 children were
delivered in this institution, all 7 children were normal deliveries.

PERSONAL AND SOCIAL HISTORY:

 The patient lives at a 2-storey house with 5 rooms and 10 occupants in a congested
neighborhood. The source of drinking water is from the water refilling station and the
water used for domestic purposes such as cooking and laundry is from the deep well.
The toilet is a water sealed latrine type. Their garbage is collected daily. They have 1
dog and 2 cats as pets.

 Patient is a non-smoker, denies drinking alcoholic beverage and use of illicit drugs.
Sometimes exposed to secondhand smoke. Claims to be noncompliant with DM
medications because of financial reasons.

 Daily meals consist of the ff:

Breakfast: coffee and bread
Lunch: rice, vegetables, fish, meat sometimes fruits
Dinner: rice, vegetables, fish and meat
Snacks: soft-drinks and biscuits or bread

 Goes to church on Sundays when able, do walking about 200 meters 3 times a week as
a form of exercise. Registered to the senior citizen club of their municipality but
seldom participates in the community activities. Prefers to stay at home and rest.
Sleeps 5 to 7 hours at night and uses 2 pillows for sleeping.

14
REVIEW OF SYSTEMS:
 General: (-)weight loss, (-)febrile episodes, (-)chills, (-)sweat, (-)irritability, (-) lethargy.

 Integumentary: (-) cyanosis, (-) pallor, (-) jaundice, (-) lesion, (-)rash, (-) dry skin

Head, Eyes, Ears, Nose, Throat (HEENT):

 Head: (-) history of head injury, (-) Headache

 Eyes: (-) blurring of vision, (-)pain, (-)redness, (-)spots, (-)specks, & (-)
sunkeneyeballs.

 Ears: (-)earaches,(-)tinnitus,(-)discharges, normally aligned ears.

 Nose: (-) cold, (-)nasal stuffiness,(-)discharge,(-)itching,(-)nosebleed (-) smell

 Mouth And Throat:(-) bleeding of gums,(-) sore throat ,(-)ulcer, (-) hoarseness, (-)
soreness , (-) dental caries, (-) enlarging tonsils.

 Neck: (-) swollen glands.(-) lumps,(-)goiter,(-)pain and(-)stiffness of the neck.

 Respiratory: (+) sputum, (-) haemoptysis, (-)dyspnea, (-)shortness of breath.

 Cardiovascular: (-)adynamic precordium, (-)NRRR , (-)murmurs (-) palpitations

 Gastrointestinal: (-)vomiting, (-)diarrhoea, (-) abdominal pain, (-)bleeding, (-) GOOD

Appetite, (-) Hematochezia

 Urinary: (-) oliguria, (-)nocturia, (-)urgency, (-) hematuria.

 Genital: (-) discharge, (-) pain, (-) swelling, (-) tenderness, (-) itchiness

 Musculoskeletal: (-) stiffness, (-)deformities, (-) tenderness,

 Neurologic: (-) Irritable, (-)changes in orientation, (-)memory loss, (-)fainting,

(-)seizures, (-)motor or sensory loss.

 Extremities: (-) numbnesss

PHYSICAL EXAMINATION:
General Survey: Conscious , oriented , conversant, not in respiratory distress
Vital Signs: BP 100/70, CR 95, RR 20, SPO2 99, T 37.1
Skin: No pallor , no jaundice, no cyanosis warm to touch

15
HEENT:
Eyes: Anicteric, pink palpable sclera
Nose: (-)discharge, (-)congestion
Mouth and pharynx: Normal oral mucosa.
Neck: (-) deformities, (-) lesions, (-) swelling, (-) CLAD, (-) tenderness.
Chestand Lung: SCE,(-)lagging, (-)retraction, (+) crackles, left side, (-) diffuse wheezing,
Heart: Irregular heart beat, (-) thrills , AP (-) murmur
Abdomen: flat, soft, (-) hypogastric tenderness, normoactive bowel sounds, globular.
Genitalia: not assessed
Extremities: full and equal pluses, no edema

NEUROLOGICAL EXAMINATION:
 Cerebrum : Apparently coherent, conscious, awake

 Cerebellum (-)tremors, (-)nystagmus, (-)ataxia

 Cranial Nerves :

 CN I : (+)smell

 CN II : (+) visual acuity intact

 CN II and CN III: pupillary reflex equal for both eyes

 CN III, IV, VI : Intact EOM

 CN V : (+)corneal reflex, (+)chew

 CN VII : symmetric nasolabial folds on smiling

 CN VIII : intact hearing ability.

 CN IX , X: uvula at midline,(+) Gag Reflex

 CN XI : Able to shrug Shoulder, able to move head from side to side.

 CN XII :able to protrude tongue,(-)deviation.

 Babinski (-)
16
  Ankle clonus (-)

 Kernigs sign (-)

 Brudzinski sign (-)

ADMITTING DIAGNOSIS: PRESENT WORKING IMPRESSION:

 TYPE 2 DIABETES MELLITUS, CAP-MR,
UNCONTROLLED R/O PULMONARY NEW GROWTH,
TYPE 2 DIABETES MELLITUS,
 ACUTE COMPLICATED CYSTITIS UNCONTROLLED
ACUTE COMPLICATED CYSTITIS,
 CAP-MR ANEMIA PROBABLY NUTRITIONAL

PLAN:
THERAPEUTICS:
DIET: dm diet
IVF:PNSS 1L 83-84 CC/HR
MEDICATIONS:
1. Ceftriaxone 2G IV OD diluted in 90 cc PNSS
2. Azithromycin 500 mg/tab OD
3. NAC 600MG/TAB 1TAB IN ½ GLASS OF WATER OD
4. HUMAN INSULIN ISOPHANE 70/30 6 UNITS SQ PRE-BREAKFAST & 8 UNITS SQ PRE-
DINNER
5. METFORMIN 500MG/TAB TID
6. ROSUVASTATIN 20MG/TAB OD
CBG MONIORING PREBREAKFAST AND PRE DINNER
Monitor vital signs every 4 hours
Input & output qshift & record
WOF: vomiting, dizziness, desaturation
SIGN OUT DIAGNOSIS:
CAP-MR
TYPE 2 DIABETES MELLITUS,
ACUTE CYSTITIS,
ANEMIA PROBABLY NUTRITIONAL
HOME MEDICATIONS:
 Cefixime 200mg/cap 1 cap q12 for 3 more days
 Metformin 500mg/tab 1 tab TID
17
  Rosuvastatin 20mg 1 tab OD
 Human insulin isophane 70/30 17units SQ pre-breakfast, 10 units SQ pre-dinner
 Cetirizine 10mg/tab 1 tab ODHS x 2weeks
-repeat chest x-ray after 2 weeks
Follow up on: 9/25/19 with lab results
FAMILY GENOGRAM:

FAMILY MAP ECOMAP

FRIENDS

BROTHER

PATIENT
CHURCH

LUVIMIN, 72
GRANDDAUGHTER

COMMUNITY

HEALTH CARE

RODOLFO, 50 FC, 16

ALMOST SOMETIMES HARDLY

FAMILY APGAR Part I ALWAYS (2) (1) EVER (0)

I am satisfied that I can turn my family for help

A
when something is troubling me √

I am satisfied with the way my family talks on

P √
things with me and shares problems with me

I am satisfied that my family accepts and

G supports my wishes to take on new activities or √
directions
I am satisfied with the way my family expresses
A affection and responds to emotion such as anger, √
sorrow and love
I am satisfied with the way my family and I
R
share time together √

18
 FAMILY APGAR Part I SCORE
I am satisfied that I can turn my ADAPTATION:
family for help when something The family understands that the patient have health care needs and
A 2
is troubling me despite financial difficulties, they try to maximize resources that could
be beneficial for them- health wise.
I am satisfied with the way my PARTNERSHIP:
P family talks on things with me 2 The family consult each other when problems arise in the family.
and shares problems with me

I am satisfied that my family GROWTH:

accepts and supports my wishes
G 2
to take on new activities or
directions
I am satisfied with the way my
family expresses affection and
A responds to emotion such as
anger, sorrow and love
I am satisfied with the way my
R family and I share time together
The family supports the patient in her persuasiveness and eagerness to
join or even as “sit in” pupil Daycare.
AFFECTION:
The husband and the rest of the household helps the mother as the
2
primary caregiver takes care of the patient while she’s in the hospital
and her other sibling while at home.
RESOLVE:
2 The family spends time together especially when sharing meals,
helping around on household works.

Who lives in our house? How do you get along? APGAR SCORE
Name Relationship Sex Well Fairly Poor 10 = HIGHLY
2. Reynaldo Flores Son M √
FUNCTIONAL
3. FC Flores GRANDDAUGHTER F √ SCREEM - RES:
Strongly Dis- Strongly
URCE
RESO

Agree
Questions Agree agree Disagree
(2)
(3) (1) (0)
S

We help each other in our family.

Ang bawat isa ay nagtutulungan sa aming pamilya. √
SOCIAL

We are helped by friends and other members of the community.

Natutulungan kami ng aming mga kaibigan at kasamahan sa √
komunidad.
Our culture gives our family strength.
Ang aming kultura ay nagpapatatag ng loob ng aming pamilya. √
CULTURAL

A culture of helping and cooperation in our community helps our

family.
Ang kultura ng pagtutulungan at pagmamalasakit sa aming komunidad √
ay nakatutulong sa aming pamilya.
Our faith and religion helps our family.
Ang aming pananampalataya at relihiyon ay nakatutulong sa aming √
RELIGIOUS

pamilya.

We are helped by members of our church or other religious groups.

Natutulungan kami ng aming mga kasamahan sa simbahan o mga
grupong relihiyoso. √

19
 Strongly Dis- Strongly
URCE
RESO

Agree
Questions Agree agree Disagree
(2)
(3) (1) (0)
S

We help each other in our family.

Ang bawat isa ay nagtutulungan sa aming pamilya. √
SOCIAL

We are helped by friends and other members of the community.

Natutulungan kami ng aming mga kaibigan at kasamahan sa √
komunidad.
Our culture gives our family strength.
Ang aming kultura ay nagpapatatag ng loob ng aming pamilya. √
CULTURAL

A culture of helping and cooperation in our community helps our

family.
Ang kultura ng pagtutulungan at pagmamalasakit sa aming komunidad √
ay nakatutulong sa aming pamilya.
Our faith and religion helps our family.
Ang aming pananampalataya at relihiyon ay nakatutulong sa aming √
RELIGIOUS

pamilya.

We are helped by members of our church or other religious groups.

Natutulungan kami ng aming mga kasamahan sa simbahan o mga
grupong relihiyoso. √

SCREEM Interpretation:
30-ADEQUATE FAMILY RESOURCES
TRAJECTORY OF ILLNESS;
Stage 1: Onset of Symptoms /Illness
Stage 2: Impact Phase Reaction to Diagnosis Stage
Stage 3: Major Therapeutics Efforts
Stage 4: Early Adjustment to Outcomes-Recovery Phase

FAMILY LIFE CYCLE;

STAGE: Family in Later Years

 The final stage of the Family Life Cycle
 Elderly persons must accept shifting of the generational roles
 Children will create families of their own, be responsible for their own life
decisions and play less active roles in the family circle in which they grew
up
HEALTH IMPLICATIONS:
 Depression
 Empty Nest Syndrome
 Degenerative Disorders (Parkinson’s,
Alzheimer’s, Osteoarthritis)
 Hypertension
 Diabetes Mellitus

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 FACTORS AFFECTING HOW FAMILIES COPE UP WITH ILLNESS

COMPONENTS
Family Resources
Family life cycle stage
Degree of family
functionality
Typology of illness
ENABLER/DISBALER
Disabler: Limited financial resources
Enabler: Family members concentrate within the
family
Enabler: Flexible in adapting to changes in roles, have
healthy communication lines, and provide good
emotional support
Crisis Phase

Stigma associated with the Disabler: Type 2 DM carry a social stigma because of
disease the cost of the medications, the complications that may
affect the quality of life of the patient and the
possibility that the family members may also acquire it.
WELLNESS PLAN:
• Diet and exercise are both key components of a successful strategy to beat or
managed diabetes, so is also lifestyle medication.
• For our patient and due to her age we suggest to replace her diet lifestyle and she must
comply with the medication.
• Food such as sugar sweetened beverage, trans fat white bread, pasta, rice, honey,
dried fruits and sweetened breakfast cereal should be avoided but more fibers, beans,
and vegetable should be encouraged.
• It is of important to emphasize to the patient in family for the procurement of a
glucometer and also to be taught on how to check the low blood sugar of the patient
so have to facilitate monitoring post hospital.
• In addition the patient/family should also be taught or trained on how to administer
insulin to the patient.
• Patient and family are advised on the importance of compliance of medication so have
to prevent long time complication.
• We would also advice the following vaccine to our patient and family members if it
received yet: pneumococcal vaccine, influenza vaccine, herpes zoster vaccine, MMR,
Tdap and for the 50 yr. old younger in addition to the above he should also start
screening test for diabetes while the 16yr old grandson should receive meningococcal.

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 SCREENING TOOLS- FL 73/F
RISK FACTORS ILLNESS SCREENING TOOL FREQUENCY OF
SCREENING
FAMILY HIGH SENSE FOBT EVERY 1 YEAR
HISTORY OF ESOPHAGEAL
CANCER SIGMOIDOSCOPY WITH
CANCER FOBT Q 3YEARS
EVERY 5 YEAR
EVERY 10 YEAR
COLONOSCOPY
OLD
AGE
COMPREHENSIVE
MULTIFACTORIAL
FALLS ASSESSMENT
ONCE IN LIFETIME

OLD AGE DECA OF HIP AND LUMBAR

MENOPAUSE OSTEOPOROSIS SPINE VARIOUS

TYPE 2 DM DIABETIC
BASELINE FUNDOSCOPY VARIOUS
RETINOPHATY

SCREENING TOOLS- BR 50/M

RISK FACTORS ILLNESS SCREENING TOOL FREQUENCY OF
SCREENING
FAMILY HISTORY FBS, HBA1C VAR
OF T2DM T2DM
REGULAR BP EVERY 1 YEAR
OBESITY MONITORING

LIPID PANEL
HISTORY OF HBV ANTI-HBV VAR
ILLICIT DRUGS INFECTION
USE
FAMILY HISTORY OF ESOPHAGEAL HIGH SENSITIVE FOBT EVERY 1 YEAR
CANCER CA
SIGMOIDOSCOPY W/ EVERY 5 YEARS
FOBT Q 3 YRS

22
 SCREENING TOOLS- FC/16

FC/16 (GRANDDAUGHTER)
RISK FACTORS ILLNESS SCREENING TOOL FREQUENCY OF SCREENING

Gonorrhea NAAT Var

Adolescence ( Period of
Curiosity and Peer Pressure)
HIV-AIDS Reactive Immune-assay plus Western Blot Var

Family History of Diabetes

Diabetes Mellitus FBS Var
Mellitus, Grandmother

Obesity BMI Var

Major Depressive Disorder PHQ-A or BDI-PC Var

23
 In DCFM: A Reflection

Community and family medicine is one of the most exciting department at

the hospital. Working with people (especially in community, outside the hospital)
is also my passion. But passion is not enough to go through in this department. It
requires a lot of patience and hardwork because you deal with different cases in
each community, each has story to tell. I have seen so many cases, I have treated
unique patients and I have experienced sorrow as well and that’s what make my
rotation well remembered.
As the days go by, I have more interaction with the patients, I get to learn
that they need to be treated holistically and now with the involvement of so many
factors in the community. The department deals with the physical, mental, and
social health of all patients of all ages. Moreover, it encompasses a broad spectrum
of health services ranging from preventive health care to the diagnosis and
treatment of acute and chronic diseases.
In relation to what I have expected, I was able to competently practice the
principles of community and family medicine, for I have able to applied what I
have learned during my school days, I have also seen the real situation in the
community. I thought that in this time of era, everyone has the access to medical
healthcare, then in this rotation, I realized, it still needs improvement.

Lastly, I was able to effectively communicate with the patients even with
language and cultural differences. Overall, I have learned so much in this rotation
that you cannot learn in the books.

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DOCUMENTATION

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