Department of Family and Community Medicine

Perpetual Succour Hospital

Gorordo Avenue, Lahug, Cebu City

A Family Case Presentation

A SECOND CHANCE

Entry for Family Case Contest

April 2016

Submitted by:

CARLA MARIE JADUCANA, MD

Total # of pages: 44

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 Table of Contents

Page Number
I. Title Page 1
II. Table of Contents 2
III. Introduction 3
IV. The Index Case 3
V. History of Present Illness 4
VI. Review of Systems 4
VII. Physical Examination 5
VIII. Salient Features 7
IX. Case Discussion
a. Substance Use Disorder 8
b. Gender Identity and Sexual Preference 9
c. Community Acquired Pneumonia 10
X. Situational Analysis 14
XI. Family Profile 20
a. Family Budget 21
b. Family Structure 21
i. Family Genogram 23
ii. Family Circle 24
iii. Family Lifeline 25
iv. Family Map 28
v. Family APGAR 29
vi. SCREEM 31
vii. Ecomap 34
viii. Family Life Cycle 37
ix. Family Illness Trajectory 37
x. Family Wellness Plan 41
XII. Summary 43
XIII. References 44

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INTRODUCTION

With everything that has happened to you, you can either feel sorry for yourself or treat

what has happened as gift. Everything that has happened is either an opportunity to grow or an

obstacle to keep you from going. You get to choose.

Our mistakes do not define us. Rather, it drives us to grow holistically to become a better

version of ourselves.

A Second Chance.

Curious little Emelita grew up in a loving family. As years passed by, she started having

second thoughts about her sexuality. A fork struck in the road and she found herself under the

influence of drugs and alcohol. She loved and lost and felt she lost everything. One bad

decision led to another and she got pregnant with her first child to a man she barely knew. The

road ahead seemed uncertain. But one day, she woke up and realized that she was her own

hero.

THE INDEX CASE

This is a case of E.G., is a 37-year old female, single parent, Filipino, Roman Catholic,

working as a fish vendor at their local public market currently residing at Sitio A, Barangay B,

Cebu City and with a chief complaint of dyspnea.

Patient is a non-hypertensive, non-diabetic nor an asthmatic. No known food or drug

allergies. No previous surgeries or hospitalizations. OB score: G1P1 (1001) delivered via NSD,

home delivered assisted by a midwife.

Patient is a cigarette smoker for 7 pack years consuming 20 sticks per day. She is also

an alcoholic beverage drinker for 7 years, usually drinking rhum (Tanduay) to point of

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intoxication. Patient is also a methamphetamine (shabu) drug user for 16 years, last use was on

March 2016.

She had 4 serious relationships all with a female partner. Presently, she is not in a

romantic relationship.

HISTORY OF PRESENT ILLNESS

One week prior to admission, patient was noted to have onset of productive cough with

whitish sputum associated with undocumented fever and body malaise. She self-medicated with

Paracetamol (Biogesic) 500mg/tablet, 1 tab as needed for fever with temporary relief. No

consult done, condition tolerated.

Hours prior to admission, persistence of symptoms noted now associated with onset of

shortness of breath. Patient was then brought to a government hospital for further management.

Patient was admitted at the government hospital for 10 days, diagnosed of Community

Acquired Pneumonia, Moderate Risk and was discharged improved with take home

medications- cefuroxime 500mg/ tablet, 1 tablet, 2 x a day for 7 days; Omeprazole 40 mg/tablet,

1 tablet, PO, once daily for 7 days, which patient took with good compliance.

Patient still complained of occasional cough, shortness of breath and dyspnea on

exertion, thus sought consult. On physical exam, patient was tachypneic at 25 cycles per

minute. Chest and lungs revealed bibasal rales, no retractions. Patient was on her 2 nd day of

taking Cefuroxime 500mg/tablet, 1 tablet BID for 7 days and Omeprazole 40mg/tablet, 1 tablet

once a day before breakfast.

REVIEW OF SYSTEMS:

 General: (-) fever, (-) chills, (-) weight loss, (+) weakness

 Skin: (-) skin lesions, (-) rash, (-) laceration, (-) bruising

 Head: (-) headache, (-) injury, (-) dizziness, (-) lightheadedness

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  Eyes: (-) acuity change, (-) pain, (-) history of corrective lens use

 ENT: (-) ear pain, (-) tinnitus, (-) nasal discharge, (-) sore throat

 Neck: (-) tenderness, (-) swelling, (-) neck pain

 Cardio-vascular: (-) chest pain, (-) palpitations, (-) orthopnea, (-) syncope

 Pulmonary: (+) shortness of breath, (+) cough, (-) wheezing, (-) hemoptysis

 Gastrointestinal: (-) nausea, (-) vomiting, (-) diarrhea, (-) melena, (-) hematochezia

 OB/GYN: (-) vaginal discharge, (-) abnormal bleed, (-) pruritus

 Musculoskeletal: (-) back problems

 Neurological: (-) focal weakness, (-) seizure, (-) dizziness, (-) numbness

 Psychiatric: (-) depression, (-) anxiety, (-) suicidal ideation, (-) paranoia

 Hematopoietic: (-) bruising, (-) adenopathy

 Endocrine: (-) polyuria, (-) polydipsia

 Allergic/Immuno: (-) urticaria, (-) hay fever

PHYSICAL EXAMINATION:

General Survey: Awake, responsive, sthenic with the following vital signs:

T: 37 oC/axilla BP: 120/90 mmHg left arm, sitting PR: 70 bpm RR: 25 cpm

Wt: 50 kg Ht: 151 cm BMI: 21.9 kg/m2 (normal weight)

Skin: brown complexion, moist, good skin turgor and mobility, no lesions, no masses, no

erythema, no areas of tenderness, non-diaphoretic

Head: black hair, evenly distributed, no flakes, no lice, no nits, no masses or areas of

tenderness

Ears: (-) tug test, tympanic membrane pearly gray with cone of light directed anteriorly

downwards, no redness or exudates

Eyes: symmetric brows, equal palpebral fissures, pinkish palpebral conjunctiva bilaterally,

anicteric sclera, pupils 3 mm/3 mm, clear cornea and leans, no redness, no itching, no tearing

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Nose: septum at midline, no alar flaring, patent nares, no masses or lesions

Mouth: incomplete dentition with dental caries, moist lips and moist oral mucosa, no

tonsillopharyngeal congestion or redness, uvula at midline, no lesions

Neck: supple, trachea at midline, (-)LAD, neck veins not engorged, non-palpable thyroid gland,

moves with deglutition

Chest and Lungs: symmetric, equal chest expansion, vesicular breath sounds,

(+) bibasal rales, (-) wheezing

CVS: adynamic precordium, distinct S1 and S2, PMI at 5 th left ICS 9cm from MSL, normal rate,

regular rhythm, no murmur, thrills, or heaves

Abdomen: flabby, normoactive bowel sounds, tympanitic, no organomegaly, no areas of

tenderness, no lesions

GUT: (-) costovertebral angle tenderness

Extremities: CRT < 2 seconds, strong peripheral pulses all extremities, no pallor, no edema, no

clubbing

Neurologic Exam:

Cerebral: conscious, coherent, oriented to time, place, and person

Cerebellar: smooth, well-coordinated movements with finger to nose test and supination

pronation test

Cranial Nerves:

I – intact

II, III – pupils equally round and reactive to light and accommodation, direct and consensual,

bilaterally

III, IV, VI – full range EOM via finger following test

V – (+) facial sensations, strong muscles of mastication

V, VII – (+) corneal reflex, bilaterally

VII – able to wrinkle forehead, able to puff cheeks, symmetrically

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VIII – able to hear whispered and spoken words at 2 feet distance, bilaterally

IX, X – (+) gag reflex

XI – able to raise shoulders against resistance

XII – tongue midline on protrusion

Sensory: pain, touch, proprioception intact

Motor: good muscle tone and bulk, no fasciculation, muscle strength 5/5 all extremities

DTR: +2

(-) Babinski Sign

SALIENT FEATURES:

1. E.G, 37-year old female, single mother

2. (-) HPN, DM, BA

3. (-) surgical history

4. G1P1 (1001)

5. (+) cigarette smoker for 7 pack years

6. (+) alcoholic drinker for 7 years

7. (+) methamphetamine (shabu) use for 12 years, last use on March 2016

8. Had 4 female (same gender) sexual partners and 1 casual male sexual partner

9. Brought to a government hospital for cough and shortness of breath, diagnosed with

Community Aqcuired Pneumonia, Moderate Risk and discharged improved

Therefore, rule-in the following working diagnosis:

1. Substance Use Disorder

2. Sexual Orientation and Gender Preference

3. Community Acquired Pneumonia- Resolving.

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CASE DISCUSSION

1. Substance-Use Disorder

According to 2008 Dangerous Drugs Board and Department of Interior and Local Government

survey-based profile, there are 1, 718, 855 users of illegal drugs and substance in the country.

Age group ranges from 10-60 years old and above. (http://www.gov.ph/2013/09/05/doh-ncr-

empowers-youth-against-illegal-drugs-and-substances/)

In 2009, study conducted by Department of Health and Department of Education in Metro

Manila and Cebu, the average age of a confirmed user is 17 years old, male to female 9:1.

Substance of choice is marijuana. (http://www.gov.ph/2013/09/05/doh-ncr-empowers-youth-

against-illegal-drugs-and-substances/)

DSM V establishes 9 types of substance related disorders: Alcohol, Caffeine, Cannabis,

Hallucinogens, Inhalants, Opioid, Sedatives, hypnotics, anxiolytics, Stimulants (cocaine,

metamphetamine), and Tobacco. (Sadock, et.al. 2015)

Regardless of the particular substance, the diagnosis of a substance use disorder is

based upon a pathologic set of behaviors related to the use of that substance. These

behaviors fall into 4 main categories- Impaired control, Social impairment, Risky use,

Pharmacologic indicators. (Sadock, et.al. 2015)

Screening, brief intervention and referral to treatment recommended for incorporation

into routine primary care by U.S. preventive services task force. Common validated

screening instrument for drugs include:

CRAFT- the only screening instrument validated for adolescents and has shown as 83%

positive predictive value, screens for alcohol and drug use

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 ASSIST- alcohol, smoking and substance involvement screening test

DAST- drug abuse screening test

Single question screen validated for primary care: “How many times in the past years have

you used an illegal drug or used a prescription medication for non-medical reasons?” This

screen has sensitivity of 100% and Specificity of 73.5%. (Rakel, et.al. 2015)

Positively screened patients but who do not meet the criteria for abuse or dependence,

receive a brief intervention, using FRAMES model or 5 A’s model- ASSESS the risk of the

behavior of the patient; ADVISE the patient on the risk and how to modify; AGREE: come to an

agreement with the patient on treatment; ASSIST the patient with the treatment plan;

ARRANGE follow-up or referral to treatment. Both are useful for patients receptive to change.

However, positive screen patients and meeting criteria for abuse or dependence are offered

referral to onsite or community drug treatment program.

Behavioral therapies are a main stay of SUD treatment (Rakel, et.al. 2015). Common

modalities include: Cognitive behavioral therapy; Contingency management; Motivational

enhancement therapy; Therapeutic Communities; 12-step facilitation.

2. Gender Identity and Sexual Preference

Sexuality is a core of personal identity. Knowledge regarding human sexual behavior in

health and illness across the life span will enable family physicians to provide appropriate care

to patients who are experiencing sexual difficulties. The following terms are important to note,

as defined by Rakel 2015:

TRANSSEXUAL – usually desire full hormonal transition and sex reassignment surgery

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 CROSS DRESSERS- “transvestites” are persons who at times may dress as other gender

to be publicly perceived as such off for sexual pleasure

TRANSGENDERED- one who seeks to take on the social role of the other gender, either

full- or part-time, often with the assistance of hormone therapy but does not desire genital

surgery

However several issues are important to remember for the medical care of LGBT

patients:

1. Lesbians less likely to obtain health maintenance services including clinical breast

examination, mammogram because of underinsured or uninsured status

2. same gender couples often are not eligible for spousal health insurance benefits

3. nulliparous lesbians have high risk for cancers –breast, endometrium and ovary

4. female-to-female transmission of STD are less efficient than male to male

Transgender health not only encounter difficulty in obtaining adequate medical services

but also suffer “hate crime” victimization, with more than half reporting harassment or violence.

3. Community Acquired Pneumonia (CAP)

Introduction

Community Acquired Pneumonia (CAP) is one of the most common infectious diseases

and is an important cause of mortality and morbidity worldwide.

Etiopathogenesis

Lower respiratory tract infection (pulmonary parenchyma) acquired in the community

within 24 hours to less than 2 weeks

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 Results from the proliferation of microbial pathogens at the alveolar level and the host’s

response to those pathogens

Most common access of microorganisms to the lower respiratory tract is through

aspiration from the orpharynx

Table1. Classification and Disposition of Community-Acquired Pneumonia

LOW RISK CAP MODERATE RISK CAP HIGH RISK CAP

Vital signs Stable Unstable

RR <30/min RR >30/min

PR <125/min PR >125/min

Temp 36-40°C Temp >40°C or < 36°C Any of the criteria

under Moderate Risk
BP > 90/60 mmHg BP < 90/60 mmHg CAP, plus:

• Severe sepsis
and septic
shock

• Need for
Features No altered mental state Altered mental state of mechanical
of acute onset acute onset ventilation
No suspected aspiration Suspected aspiration

No or stable comorbids Decompensated

comorbidities

Chest xray Localized infiltrates Multilobar infiltrates

No pleural effusion Pleural effusion

No abscess Abscess

Disposition Outpatient Ward Admission ICU admission

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Diagnostics for CAP

 Chest Radiography: Essential in the diagnosis of CAP, assessing severity, differentiating

pneumonia from other conditions and in prognostication

 Microbiologic Studies (sputum & blood cultures)

 Optional in low-risk CAP

 Necessary in moderate and high-risk CAP

 Invasive procedures (eg. bronchoalveolar lavage, transtracheal/ transthoracic biopsy,

protected brush specimen): Options for nonresolving pneumonia, immunocompromised

patients and in patients in whom no adequate specimens can be sent

Management

Table2. Potential Pathogens and Management of Community Acquired Pneumonia

Risk Potential Pathogens Empiric Therapy

Stratification

Low-risk Streptococcus pneumoniae, Previously Healthy:

Hemophilus influenzae,
CAP Amoxicillin or extended macrolide
Chlamydophila pneumoniae,
(suspected atypical pathogen)
Mycoplasma pneumoniae,

Moraxella catarrhalis, Enteric gram With Stable comorbids:

negative bacilli (among those with

B-lacam/BLIC or 2nd gen oral
comorbids)
cephalosporins + extended macrolide

Althernative: 3rd gen cephalosporin +

extended macrolide

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Moderate- Streptococcus pneumoniae, IV non-pseudomonal B-lactam (BLIC,

risk CAP Hemophilus influenzae, cephalosporin or carbapenem) +

Chlamydophila pneumoniae, extended macrolide or +respiratory

Mycoplasma pneumoniae, quinolone (FQ)

Moraxella catarrhalis, Enteric gram

negative bacilli (among those with

comorbids), Legionella

pneumophila, Anareobes

High-risk Streptococcus pneumoniae, No Risk for P. aeruginosa:

CAP Hemophilus influenzae,

IV non-pseudomonal B-lactam + IV
Chlamydophila pneumoniae,
extended macrolide or + IV respiratory
Mycoplasma pneumoniae,
quinolone (FQ)
Moraxella catarrhalis, Enteric gram

negative bacilli (among those with Risk for P. aeruginosa:

comorbids), Legionella IV anti pneumococcal anti

pneumophila, Anareobes, S. pseudomonal B-lactam + IV extended
aureus, P. aeruginosa macrolide + aminoglycoside

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SITUATIONAL ANALYSIS

1. Home:

The Gallardo’s residence is situated in Sitio A, Barangay B, Cebu City. The index patient

owns the house with three rooms. The house is made up of light, mixed materials. The walls

and windows are made of wood with 2 doors and 4 windows (Figure 1). This old house is

adjacent to their new house which is still under construction (Figure 2). Their old house has no

flooring and is built directly on top of soil, while the new house has concrete flooring. They all

sleep in their old house, while the second house is still not finished nor furnished, which serves

as storage room as of the moment. The cooking is done outside the house with the use of wood

(Figure 3). There are three bedrooms, the first serves as the living room where they spend time

together when they watch television during their leisure time (Figure 4-A), the second is the

room of the index patient and her son (Figure 4-B), the third and the largest is occupied by the

index patient’s parents (Figure 4-C). The family has two comfort rooms which are both water-

sealed located inside both of their houses respectively (Figure 5). Their water supply is from the

city water district (Spider) (Figure 6). They buy water for drinking which is approximately 50

pesos per month. Their light sources are electric bulbs in each room respectively, powered by

Visayan Electric Company (VECO) (Figure 7).

2. Neighbourhood

The houses in their neighbourhood are of close proximity to each other, approximately

not more than 5 meters from one house to another.

3. Work place

The index patient works at the Barangay Public Market which is approximately 3 kilo

meters from their house, as a fish vendor together with her siblings.

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 A

Fig1. Façade of the index patient’s house

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Figure2. On-going construction of the 2nd house

Figure3. Cooking area outside the house

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 A B

Figure4. Three bedrooms

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 A

Figure5. Water-sealed type comfort rooms located inside the house

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Figure6. Water Source

Figure7. Light Source

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FAMILY PROFILE

The family is an extended type and is composed of 4 members. Members are as follows:

Emelita, our index patient, is the pprimary caregiver. She is a 37-year old single mother. She

is currently unemployed but previously worked as fish vendor in the sister’s stall. She is non-

hypertensive, non-diabetic, no food and drug allergies. She is a smoker for 3 pack years;

occasional alcoholic drinker for more than 5 years, illicit drug user (methamphetamine) since

2001, and last use was on April 2, 2016.

Cesario, the father of the index patient, is 74 years old, sells livestock (chicken) for a living.

He is hypertensive for 3 years, however non-compliant to medications (unrecalled), non-

diabetic; non-asthmatic, no food and drug allergies. He is a smoker for 25 pack years and an

occasional alcoholic drinker (one bottle of beer/rhum per week) for 50 years. He denies use of

illegal drugs.

Victoriana, 72 years old is the mother of the index patient. She also sells livestock (chicken)

for a living together with her husband. She is non-hypertensive and has no food and drug

allergies. She is however diabetic for 4 years with maintenance medications: Insulin (22 units in

the morning and 14 units afternoon), Irbesartan, Linagliptin, Metformin Amlodipine, Cilostazole,

and Gabapentin. She had a below the knee amputation, right leg, last 2012 at a government

hospital due to her diabetic foot. She is a non-smoker, non-alcoholic and denies of any history

of illicit drug use.

Kyle, is theonly son of Emelita. He is 8 years old and currently a 4th grader at the local

Baranagay Elementary School. He has no known medical problem and no food and drug

allergies. He is a non-smoker, non-alcoholic beverage drinker, with no history of illicit drug use.

They are all Roman Catholic by religion.

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 1. FAMILY BUDGET

The Gallardo Family averages a monthly income of Php 6,000-6,500. Of which, 35% of

the budget is allocated for food since her sister, Leny, gives her a monthly supply of fish; 30%

for Kyle’s education inclusive of his fare and school baon, 25% for the medicines of both of her

parents and 10% for their water and electricity.

Food
30% 35% Water and
Electricity
Medicines

Education

25% 10%

Figure 8.Pie Chart showing the breakdown of the Gallardo Family’s Budget

2. FAMILY STRUCTURE

The structure of the family is contributed by the roles played by the members of the

family, the rules governing their practices, and transactional patterns. In the Gallardo

family, the bread winner is Emelita, who works as a fish vendor (Figure 9) in the Lahug

Market fish stall owned by her sister, Liza. The decision maker and primary caregiver is

Emelita. Victoriana, index patient’s mother, is the adviser/consultant whom our index

patient relies on for advice regarding financial problems and issues on vices. Kyle, being

the only child, is the darling of the family, gives them joy and lights up their life. Being a

family with young children, first order change was achieved when Emelita lived together

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with Kyle and her parents; second order change was achieved when Emelita performed

her role being a good parent to Kyle by quitting use of drugs and working hard as a fish

vendor.

Figure 9.Showing the index patient in Lahug Public Market as fish vendor

Gallardo family has both overt and covert rules which they religiously comply. It is

an established rule that Emelita gets budget from Lisa (patient’s sister) for food and

medications and Kyle (patient’s son) should be at home for lunch so that he can eat

together with her mother, or else he will be subject to disciplinary actions. Implied rules

which the family practiced across generations include taking care of the elders and

showing them respect, and giving importance to education.

Transactional pattern is evident in the grandparents spoiling their grandchildren.

Most conflicts arise between the Emelita and her brother (Melchor). At time of conflict,

patient is supported by her mother and her sisters (Lisa, Vangie, and Elenita).

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A. FAMILY GENOGRAM (Figure10)
DEAN-GALLARDO
DEAN-GALLARDO FAMILY
SITIO
SITIOLAGUERTA,
A, BARANGAYLAHUG, CEBU
B, CEBU CITY
CITY
APRIL15,
APRIL 15,2016
2016

Dean-Gallardo family lives in Sitio Laguerta, Lahug, Cebu City.

Figure 10. Genogram of the Dean-Gallardo Family done on April 5, 2016

Dean-Gallardo Family resides in Sitio A, Barangay B, Cebu City. Cesario,

76 years old, and Victorian, 72 years old, were married last 1968 and started living

together. They were blessed with 7 children, namely Evangeline, 45 years old; Elenita,

43 years old; Fredo, 41 years old; Lisa, 40 years old; Emelita, our index patient; Junior,

34 years old; and Melchor, 33 years old. Emelita had 2 serious intimate partners. Her

first common-law partner for 9 years is Ritchelle, 30-year old female, who ended up

marrying Jimboy, 30-year old male at 2014 and both had a son. While Emelita was in a

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 relationship with Ritchelle, she had a one-night stand with Viong, 25-year old male who

has a wife, Christine, 25-year old female, and a son. Viong and Emelita are frequent

acquaintance because they do drugs together. The one-night stand with Viong led to

Emelita’s pregnancy. She then delivered via normal spontaneous delivery, Kyle who is

now 8 years old. Emelita, after ending her relationship with Ritchelle, found comfort and

love in the arms of Winnie, a 27-year old female prostitute from Mindanao and a mother

of 4 children with her common-law partner, Herbert, 29-year old male, whom she left

behind at Mindanao. It was during this time when Emelita got hooked to drugs. Although

Emelita claimed that Winnie accepted Kyle whole-heatedly, conflicts between the couple

grew bigger. Emelita and Winnie separated at 2010. Winnie then married Roy, 27-year

old male, who was just their neighbor. At present, Emelita claimed that she is not in a

relationship and currently lives together with her parents and her son.

B. FAMILY CIRCLE (Figure 11)

Figure 11. Family Circle in the perspective of Emelita with a Reliability Score of
90%

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 Figure 11 shows Family Circle in the stand point of our index patient. This showed that she

has no conflict with anyone. She is closest to Kyle. Next persons she hold close to her heart are

her parents and sisters- Liza and Leny. Other persons she turn to at times of trials include her

other siblings- Cesario, Evangeline and Melchor; and neighbors- Charevie and Rose, who are

our Barangay Health Workers.

C. FAMILY LIFELINE
Table 3. Family Lifeline of Gallrado Family with important events and Impact on the index patient

Date: Age: Event Impact

1978  Emelita was born

1987 9 yrs  Emelita was noted to prefer things for boys

old and dress up like a boy

1998 20 yrs  Had a relationship with Ritchelle and lived

old together for 9 years

2000 22 yrs  First met Viong through common friends

old

2001 23 yrs  Emelita started using illicit drug s

old (methamphetamine) influenced by her

peers particularly by Rio Hapso

 Started her vices (smoking and drinking)

2006 28 yrs  Had a session with Viong, had a one night

old stand, while in a relationship with Ritchelle

 Became pregnant with Viong’s baby

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2007 29 yrs old  Her 9 year relationship with Ritchelle

ended because of another man whom

Ritchelle married

 Gave birth to her first son, Kyle

 She heard from her neighbors that Viong

died from drug overdose and suffered a

heart attack

 Had a relationship with Winnie

(prostitute) from Mindanao who has 4

children of her own and they lived

together for 3 years

2010 32 yrs old  Her 3-year relationship with Winnie

ended, Winnie ended up marrying their

neighbor, Roy

2012 34 yrs old  Her mother suffered from diabetic foot

and had a below the knee amputation on

her right leg at a government hospital

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March 37 yrs old  She was admitted due to dyspnea and

2016 cough at a government hospital

 Claimed last use of illicit drug is at this

time

April 37 yrs old  Patient was first seen and examined

2016
 Interventions done, with regular follow-

up at the Wellness Clinic, patient was

glad to receive free health care service

and medications

June 37 yrs old  Follow-up visit done, with continued

2016 appraisal to have behavioral therapy at

local Rehabilitation Center, but patient

still refused

 Patient is happy making a living by

working regularly at the Barangay Public

Market and claimed to be drug-free for

more than 2 months now

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 D. FAMILY MAP

Figure 12.Family Map of Gallardo Family

Gallardo family has 4 house hold members who are in a good relationship. Emelita takes

good care of her and her parents and claimed to have a good communication and fairly close

relationship with them. Petty conflicts cannot be absent in their relationship, especially about her

father’s vices and financial constraints, but is easily resolved and not big enough to cause strain

in their relationship.

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 E. FAMILY APGAR

Table4.APGAR Score in the perspective of Emelita with Reliability of 85%

Almost Always Some of the time Hardly Ever

(2) (1) (0)

Adaptation: I am satisfied that I

can turn to my family for help

when something is troubling me.

Partnership: I am satisfied with

the way my family talks over

things with me and shares

problems with me.

Growth: I am satisfied that my

family accepts and support my

wishes to take on new activities

and directions.

Affection: I am satisfied with the

way my family expresses affection

and responds to my emotions.

Resolve: I am satisfied with the

way my family and I share time

together.

Table 4 shows Emelita’s perception and level of satisfaction on the current state of her

family members’ relationships. The total score obtained from the parameters is 7, which means

that the family is a MODERATELY DYSFUNCTIONAL family.

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 Our index patient can easily ask the advice of her parents whenever she has some

problems. She believes her parents and also siblings (even though they aren’t living with them)

have been very understanding of her. In fact, despite her vices, her family still welcomes her,

encourages her to be better and gives her job opportunities. Therefore, she is giving Adaptation

a score of 2 or Almost Always.

The family altogether solves any problems that arise within them. With regards to

financial problems, Emelita’s siblings are generous and are always willing to extend help no

matter how difficult procuring money is. As verbalized by the patient, “Bahala lang gud ug

ginagmay,basta tinabangay lang. Kung sila pud naay problema, mutabang man pud ko.”

Therefore, the index patient gave Partnership a score of 1 or Some of the Time.

Emelita claimed that her family is always supportive of her. In fact, her parents would

have wanted her to finish studies. Unfortunately, when she was still young, she felt that her

parents were too busy in their work, that’s she gave up on studying. When she was under the

influence of drugs, her family was deeply saddened, and would always reprimand her. This

made her give Growth a score of 2 or Almost Always.

Even though Emelita’s family has been supportive of her, she admitted that they are not

very vocal of their feelings. She admitted that they are not used to sharing gestures of love and

compassion. Although she believes that these values are present in their family. These made

her give Affection a score of 1 or Some of the Time.

Our patient claimed that they don’t have much time to spend together especially for

leisure. But every time that they are together, she is contented with how the family bonds

together, especially with her son. This made her give Resolve a score of 1 or Some of the Time.

30
 F. SCREEM

SOCIAL

The Gallardo family has a positive relationship and evident social interaction among

themselves and with their neighbours. There are no major conflicts among the members of the

family. They relate well with their neighbours. They practice open communication and often

participate in community activities, thus making the SOCIAL ASPECT a RESOURCE.

CULTURE

The family does not feel any ethnic nor cultural inferiority. The parents believe that they

have taught their children the good character of a Filipino citizen. The family members share the

same beliefs and practices. The neighbourhood is generally a community of Roman Catholic

Filipinos who share the same beliefs and cultural identity with their family, thus making their

CULTURE a STRENGTH or RESOURCE.

RELIGION

The entire family is Roman Catholic. Although, the family claimed that they cannot

attend Sunday masses sometimes and rarely join religious activities. The family have no

differences regarding religious practice. In fact, they believe that they have strong divine faith

despite their struggles in life. This makes their Religion aspect both a RESOURCE and

PATHOLOGY.

EDUCATIONAL

The educational attainment of Emelita is high school level. She only finished the first

year. During her elementary years, she was known to be a consistent honor student. However,

when she reached high school, her parents cannot take care and watch over her constantly

31
because they had to tend their fish business, hence, Emelita didn’t pursue her studies.

Moreover, Emelita’s child Kyle is currently a 4th grader at Lahug Elementary School. These

made Education PATHOLOGY for their family. Despite her educational attainment, Emelital can

still get through her day to day problems by being “ma-deskarte sa buhay.” Emelita still regards

Education important, making her work hard to send Kyle to school and hoped in the future her

son will attain a college diploma in his chosen field. These make Education a STRENGTH at the

same time.

ECONOMIC

The family is living at a stable monthly income of at least Php 6,000 – P 6, 500.00, which

they consider as enough to meet their daily needs. Emelita and her siblings are currently

earning money by selling fresh fish in the market. They are contented. Emelita’ siblings,

although not currently living with them, don’t have any problem sharing the responsibility of

providing for the family. However the family is aware that sometimes their income is not

sufficient for their needs. This aspect is considered a STRENGTH and a PATHOLOGY for their

family.

MEDICAL

Emelita claimed that the family is actually eager to get medical help when the need

arises but becomes hesitant sometimes due to the worry of having to spend a lot for their

medications. Their proximity to the Wellness Clinic make health services readily available. This

makes the MEDICAL aspect both a STRENGTH and a PATHOLOGY.

32
 Table5.SCREEM in the perspective of Emelita with Reliability of 85%
PARAMETERS STRENGTHS/RESOURCES WEAKNESS/PATHOLOGY

Social Evident social interaction, open Isolated from extra familial

communication among Problem of over commitment

members, involved in community

groups

Cultural Cultural pride or satisfaction, Ethnic/cultural inferiority

especially in distinct ethnic

groups

Religious Satisfied with spiritual Rigid dogma/rituals

experiences, contacts with extra

familial support group

Educational Adequate education to allow Handicapped to comprehend

members to solve/comprehend

problems within the format of the

lifestyle

Economic Stable/sufficient to provide Economic deficiency

reasonable satisfaction, can Inappropriate economic plan

meet economic demands of

normal life

Medical Health care available, has Not utilizing health care

previous satisfactory experience facilities/resources

with health personnel

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 G. ECOMAP

Figure13. Eco-Map showing the relationship of the index patient to her family and
environment before intervention was given

Emelita, the index patient has a good relationship among her family members. They

maintain an open communication and always support each other despite not living together

under one house. At times of hardships and challenges, financially or emotionally, she first asks

for help from her siblings, thus placing the family in the 1st orbit and showing a good

relationship between them.

The 2nd orbit is occupied by source of income, being a fish vendor, since it has helped

her in many ways, especially providing the basic needs for her family. She has a fair relationship

34
with this establishment, because she goes to the market occasionally, only if need arises. Her

sister owns the establishment, making her confident that it will always be around when she

needs it most. Thus, income is not at a regular basis.

The 3rd orbit is occupied by the community, including the neighbors and barangay

health workers who also help her in some of the problems concerning health and growth. They

have a fair relationship, since the neighbors also have problems of their own, they do not give

the index patient their 100% attention. The barangay health workers were being taken for

granted by Emelita but her illness showed her their sincerity in helping, thus little by little, she

now regards them of great importance in their lives.

The 4th orbit is occupied by our Family and Community Medicine Wellness Clinic,

including the doctors and volunteers. Their family have been under the care of this institution for

over 4 years now, with Emelita’s mother, being diabetic and elderly, benefiting the most. But the

relationship is only fair since our index patient takes her health for granted.

The 5th and outermost orbit is occupied by religion. Although all members of the

household of our index patient share in the same faith, Emelita confided that she is not religious,

unlike her mother. It is the last resort to her problems.

35
 Figure14. Eco-Map showing the relationship of the index patient to her family and
environment after giving intervention

Interventions made a difference in our index patient’s relationship with the environment,

as shown by the difference between figures 13 and 14. In the 1 st orbit, there was no difference.

Good relationship between Emelita and her siblings was maintained.

In the 2nd orbit, patient’s source of income is already regarded as important. She now

goes to the market to sell fish, in a regular basis, thus income is more stable. Counselling

helped her decide to spend time in income generating activities rather than in staying at home

and be continually tempted to use drugs and alcohol.

36
 The change in the 3rd orbit is reflected by our index patient’s good relationship among

her neighbors and most especially with the barangay health workers. She now has new friends

who are of good influence to her. In return, she helps her community by extending hand and

volunteering in some activities, and in setting herself as a role model to those who have

Substance Used Disorder.

In the 4th orbit, our index patient showed improvement in giving importance to Health.

She now seeks regular follow-up at the Wellness Clinic, bringing along her son with her. Thus, a

good relationship is created between the establishment and the index patient.

In the 5th and outermost orbit, religion is slowly becoming important to our index patient.

Because when all else fails, she knows she can hold on to her faith. She believes that other

person keeps on praying for her and her family also. She considered the experience being in

the brink of death and making through it was a miracle.

H. FAMILY LIFE CYCLE

Based on Six-stage family cycle, Emelita’s Family is at STAGE III or the stage of

becoming parents and families with children. The key principle in this stage is accepting new

members into the system. Second order changes required to proceed developmentally includes:

making space for children, joining in child-rearing and financial and household tasks,

realignment of relationships with the extended family to include parenting and grand parenting

roles.

I. FAMILY ILLNESS TRAJECTORY

The family is currently at the Stage 4 or the Recovery phase (Adjustment to outcome).

This phase is usually marked by the disappearance of symptoms for acute, self-limiting illnesses

and returning to the home environment and some degree of functionality among chronic

37
illnesses. Adjustment to outcomes again depends on the anticipated outcomes of the disease

process and patient behaviour. A readjustment of roles might be needed in order to

accommodate the new status of the ill member. The physician must be able to prepare the

family for the potential outcomes of the disease and prepare a realistic plan.

One week prior to our family visit, Emelita was admitted at VSMMC for 7 days and was

managed as a case of Pneumonia. She underwent series of laboratory examinations like chest

x-ray and complete blood count. She was started on antibiotics and was then discharged with a

clinically improved condition. She was scheduled to have a follow up visit at the said hospital 1

week after discharge. She then had a repeat Chest x-ray which revealed negative of pneumonia

or any new findings. At that time then, she was on her second day of antibiotic therapy. We

advised her to continue her medications.

During our next visit, she had no recurrence of symptoms but claimed to have

occasional dyspnea on exertion (walking approx. 100 meters) which is easily relieved by rest.

Physical examination was unremarkable. We advised the patient and the family to observe

health care by having a good nutrition, regular exercise as tolerated, proper hygiene, and

avoidance of vices. Also, we advised our index patient, Emelita, to return immediately to the

hospital if there are any recurrences of symptoms.

INTERVENTIONS:

Problem #1: Substance Use Disorder (SUD)

United States Preventive Services Tasks Force (USPSTF) recommended routine

Primary Care of patients with or suspected of SUD to include Screening, Brief Intervention and

Referral to Treatment.

38
 Single Question Screen validated for Routine Primary Care with Sensitivity 100% and

Specificity of 73.5% - “How many times in the past years have you used an illegal drug or used

a prescription medication for non-medical reasons?” was presented to our index patient.

Outcome of the Screening is Positive since she answered more than 5 times a month use of

illicit drugs for the past 12 years. Patients with Positive result who meet the criteria for abuse or

dependence and are receptive to changes receive brief intervention. Behavioral therapies are

the main stay of SUD treatment. So, we asked help from the Cebu Office of Substance Abuse

Program (COSAP) who can provide such for free. They referred us to their allied Rehabilitation

Centers. The whole Gallardo family, including her parents and son were very supportive in this

big change in the life of our index patient. They have a common desire to help the index patient

in her struggle to a drug-free life.

After exhausting our resources in convincing her to undergo the said therapy under the

supervision of a Rehabilitation Center- The FARM (Family And Recovery Management), our

index patient still did not comply. We performed Brief Interventional Technique- 5 A’s (ASSESS

the risk of the behavior of the patient; ADVISE the patient on the risk and how to modify;

AGREE: come to an agreement with the patient on treatment; ASSIST the patient with the

treatment plan; ARRANGE follow-up or referral to treatment). Following-up regarding the

patient’s referral to Rehabilitation Center is still continued.

Problem #2: Sexual Orientation and Gender Preference

Her romantic affection towards the same gender makes her a member of the minority

and the marginalized population. Furthermore, this makes her high risk for issues on

discrimination, abuse, and health problems.

Discrimination among her family members was not felt by our index patient since her

whole family readily accepted and supported her when she opened up regarding her sexual

39
orientation and gender preference. Her mother claimed that ever since our index patient’s

childhood, she noted her to be inclined more to things which are for boys, that’s why she was

not surprised when she learnt of the index patient’s sexual orientation. This made her easy to go

out in the open, to the community, being her true self. But that was not the case with her son,

who experienced being teased and bullied of having a transgender mother. This did not make

her son hate our index patient, instead he defends her and in doing so, he grew to be a stronger

kid, and a respectful and loving son to our index patient.

We also tapped Department of Social Welfare and Development (DSWD) regarding the

living situation and environment of index patient’s son. The authority cannot intervene, unless a

complaint on abuse or neglect is passed to them. They advised us to let our index patient join

Good Parenting lectures given by Cebu City Government at Cebu Capitol, which we

recommended to our index patient. There is a positive response but due to priorities given to

work, patient is not yet amenable to attend the said lectures. Close follow-up should be

continued.

Heath issues which our index patient is at risk include sexually transmitted infection due

to having multiple sexual partners and uncommon sexual practices, and they are less likely to

obtain health maintenance services like clinical breast examination and mammogram, because

they think less of being a woman. We recommended our patient to have monthly self-breast

examination, pap smear and HPV Vaccine.

Problem #3: Community Acquired Pneumonia

We encouraged patient to have constant follow-up at the Family Wellness Clinic and to

take home medications with good compliance by giving her free medicines from the Clinic,

which included Cefuroxime 500mg/ tablet, 1 tablet, 2 x a day for 7 days and Omeprazole 40

mg/tablet, 1 tablet, PO, once daily for 7 days. Reassessment after completion of the home

40
medications revealed normal vital signs and remarkable decrease in rales upon auscultation.

Repeat Chest Radiograph was done and revealed interval decrease in the haziness and

densities on both lung fields, thus findings correspond to Community Acquired Pneumonia-

Resolving.

FAMILY WELLNESS PLAN

Emelita, the index patient, is 37- year old, single mother, fish vendor, non-hypertensive,

non-diabetic, non-asthmatic with no food and drug allergies, a smoker for 3 pack years, an

occasional alcoholic drinker for more than 5 years, and an illicit drug user (methamphetamine)

since 2001, last use was on April 2, 2016. For her, we make the following wellness plan:

Table 6. Wellness Plan for Emelita

Screening Tests Immunization Lifestyle Modification Counseling

-Weight -Influenza -Nutrition Tobacco, Alcohol,

-BMI -HPV -Healthy Weight Drugs, Environment
-BP -Pneumococcal Management and Occupational Risk
-DM & Cholesterol -Hepatitis B Factor
screening

Cesario, index patient’s father, 74 years old, hypertensive for 3 years, non-compliant to

medications (unrecalled), non-diabetic, non-asthmatic, no food and drug allergies, smoker for 25

pack years, occasional alcoholic drinker (one bottle of beer/rhum per week) for 50 years, denies

use of illegal drugs, and sells livestock (chicken) for a living. For this member of the family, we

present the following wellness plan:

Table 7. Wellness Plan for Cesario

Screening Tests Immunization Lifestyle Modification Counseling

-Comprehensive Vision - Influenza -Nutrition -discuss depression,

Screening every 1-2 -Pneumococcal 13 -low salt , low fat diet cognitive function,
years Valent Conjugate -cutting down vices dealing with death,
-DM & Cholesterol -Pneumococcal MMSE
Screening Polysaccharide
-Orthopaedic Screening -Hepatitis B

41
 Victorina, index patient’s mother, is 72-year old female, non-hypertensive, diabetic for 4

years, with good compliance to maintenance medications, non-asthmatic, non-smoker, denies

illicit drug use, and non-alcoholic beverage drinker. For this member of the family, we have the

following wellness plan:

Table 8. Wellness Plan for Victorina

Screening Tests Immunization Lifestyle Modification Counseling

Comprehensive Vision - Influenza -Nutrition -discuss depression,

Screening every 1-2 -Pneumococcal 13 -diabetic diet cognitive function,
years Valent Conjugate dealing with death,
-DM & Cholesterol -Pneumococcal MMSE
Screening Polysaccharide
-Orthopaedic Screening -Hepatitis B
-CBS monitoring

Kyle, index patient’s son, is 7-year old child, no co-morbid medical illness, non-

asthmatic, with no known food and drug allergies, growth and development at par with age, non-

smoker, no illicit drug use, non-alcoholic beverage drinker, Grade 1 student at Lahug

Elementary School. For this member of the family, we present the following wellness plan:

Table 9. Wellness Plan for Kyle

Screening Tests Immunization Lifestyle Modification Counseling

-Height -Influenza -Nutrition -general safety, injury

-Weight -2nd dose MMR -Good hygiene precaution, car seats,
-BMI -2nd dose Varicella 2nd and 3rd hand
-BP smoke
-Development Review
psychological/behavioural
assessment
-Hearing/ Vision Test

42
SUMMARY

This is a family case with an index patient- E.G., 37-year old, single mother, facing the

issues of Substance Use Disorder, Sexual Orientation and Gender Preference, and Community

Acquired Pneumonia- Moderate Risk. Her family is an Extended Family, life cycle at Stage 3, or

the Stage of Becoming Parents and Families with Children, with Family APGAR score of 7 or

Moderately Dysfunctional, and Family Illness Trajectory Stage IV or Recovery Phase.

This is an extraordinarily ordinary story. I could say it is ordinary because anyone can

relate to it, because we do have moments of grave challenges in our lives. Yet, it has become

extraordinary because of the full effort of Emelita in turning her life around, not just for herself

but most especially for her family. We all have an opportunity to take our own road to a Second

Chance and have a better life, but the question is, have we identified it yet?... and are we willing

to exert our effort in turning our life around for us to become better individuals not just for the

good of our selves but for the our family and community as well? Emelita taught us that nothing

is impossible.

For me, this case did not just teach me the importance of Second Chance, but also gave

me the opportunity to practice the multifaceted roles of a 5-Star Family Physician- Teacher/

Educator as I continually advise the patient on good health and sanitation, Counselor as I

continue to counsel the patient on Substance use prevention, Researcher as I continue to

increase my knowledge on the approach to patient who have the issues like Emelita’s,

Manager/Leader as I do my best to be committed to bringing the community to the path of

righteousness, and Social Mobilizer as I tap other government and non-government

organizations.

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REFERENCES

1. Rakel, R. et. al. Textbook of Family Medicine, 9th ed. Substance Use Disorders. Saunders,

Elsevier Inc., 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899. 2015.

2. Z. E. Leopando et.al., Textbook of Family Medicine, Volume 1: Principles, concept, practice

and context. C & E Publishing, Inc. and the Philippine Academy of Family Physicians. 839

EDSA, South Triangle, Quezon City. 2014

3. Sadok, et.al., Synopsis of Psychiatry Behavioral Sciences Cinical Psychiatry 11 th Edition.

Wolters Kluwer. Two Commerce Square, Philadephia PA 19103. 2015

4. Department Of Health (2013, September 5). Official Gazette. DOH-NCR Empowers Youth

Against Illegal Drugs And Substances. Retrieved from: http://www.gov.ph/2013/09/05/doh-ncr-

empowers-youth-against-illegal-drugs-and-substances/

5. A. Benson, Cebu City Office for Substance Abuse Prevention, June 2016 (personal interview)

6. A. Aleño, Family And Recovery Management (The FARM), June 2016 (personal interview)

44