Our Lady of Fatima University

College of Medicine
Department of Family Medicine and Community Health
120 McArthur Highway, Valenzuela City

Family Case:
FLORES Family

In partial fulfilment of the requirements for

Junior Internship Rotation in OLFU- FMCH
February 2019

CLINICAL CLERKS:
Aiko Salorsano
Salvo Geraldine Marie
Sodani Jay
Tejada Jimffel
Tenchavez, John Mary Therese

COMMITTEE
LIVELIHOOD B

PGI in CHARGE:
Efraim R. Abergas
Nico Angeles

CONSULTANT IN CHARGE:
DR. MARIA LORENA LORENZO
 Table of Contents

 Introduction
 Objectives
 General Objective
 Specific Objectives
 Clinical Case
 Family Visits (Progress Notes)
 Case Discussion
 Introduction to Family Members
 Introduction of Family Members
 Genogram
 Family Structure and Function
 Family Psychodynamics
 Family Life Cycle
 Economic Status
 Family Lifeline
 Spot Map
 Floor plan
 Family Assessment Tools
 Family Circle
 APGAR
 SCREEM
 SCREEM-RES
 Attitude Towards Health
 Impact of Illness Trajectory
 Stage in the family Illness
 Family Wellness Plan
 Group Achievements
 Recommendations
 I. INTRODUCTION

Definitions of the Family

The social unit whose primary task are socialization of children and the
stabilization of adult personalities (Parsons and Bales, 1955)

The family is a semi-closed system of actors occupying inter-related positions

defined by society of which family system is part as unique to that system with
respect to the role content of the positions and to the ideas of kinship relatedness.
(Rogers, 1973)

Significant group of intimates with a history and future. (Ransom and

Vandervoort, 1973)

The family is the unit made-up of individuals a person is related to by blood or

marriage and to whom he/she feels toes of obligation. (Gordon, 1978)

A group of people related by blood, mariages or

adoption, which live together in one household. (United Nations)

II. OBJECTIVES

A. General Objectives

To present a family-oriented case of our index patient and her family.

B. Specific Objectives:

1. To discuss the dynamics and structure of the family of the index patient
Describe the family psychodynamics, lifeline, life cycle, structure and function to
better understand the background composition of the family.

2. Enumerate different wellness program, suggestion and management to help

our index patient

3. Recommend future plans and management that will aid in the improvement of
our index patient

III. Clinical Case

General Data

I.F. 72 years old, female G4P4(4004), married, filipino, housewife,

Roman catholic, born on June 17, 1946 in Batangas City, currently residing at P.
Tarog St. Gen. T. De Leon Valenzuela. Fifth time consult at Tarog health clinic.
Chief Complaint:

Joint Pains

History of Present Illness:

2 months prior to consult, patient experienced intermittent pain on both

knee with a pain scale of 6/10, associated with morning stiffness(<30 minutes)
, non-radiating, with limitation of movement upon flexion of both knee, relieved
by stretching, resting, and applying warm compress. No associated symptoms
such as fever, swelling, erythema. Patient consulted in a medical mission in
which she was prescribed with Diclofenac Sodium 100mg/tab once a day as
needed if with severe pain, which relieved the symptoms.

Patiently was apparently well until 1 month prior to consult, patient

again experienced bilateral knee pain with the pain scale of 6/10, associated
with morning stiffness ,nonradiating, still with limitation of movement upon
flexion of both knee. She consulted at Tarog Sattelite Clinic and was advised
to continue Diclofenac Sodium 100mg/tab. No other associated symptoms
such as fever, swelling, erythema noted.

Patient was apparently well until 1 day prior to consult, patient

complained of bilateral knee joint pain and now with hip pain, Pain is
aggrevated by movement and is relieved by rest.. She rated the pain 6/10
characterize as sharp, non radiating, associated with morning stiffness, with
no limitation of movement of both knee, relieved by stretching, resting and
applying warm compress associated with occasional loss of balance when
walking.

There are no other subjective complaints such as no headache,

dizziness, fever ,no ear pain, no tinnitus, easy fatigability , cough , colds ,
difficulty of breathing , shortness of breath , sorethroat, hematemesis, night
sweats, chest pain, weight loss, no body malaise , abdominal pain, dysuria
and gross hematuria. Patient is compliant to maintenance medication except
for Fenofibrate due to due to financial insufficiency.

Few hours prior to consult patient still complained of above

symptoms.no other subjective complaint such as headache, dizziness, chest
pain, easy fatigability, body malaise noted.Persistence of symptoms prompted
consult.
 d.

Past Medical History

 Patient claimed for an unrecalled complete childhood immunizations such as

MMR, DPT, OPV,Varicella, hepatitis A and B, Pneumoccocal. She had no
adult immunizations.

 She had eczema (1990), an unrecalled topical ointment was given & applied to
the affected area which resolved.

 In 2014, She was diagnosed with Myoma Uteri. Surgery was advised but she
refused and was lost to follow-up.

 In January 2019, Patient had acute otitis externa was resolved. Patient was
diagnosed with dyslipidemia, DM type 2, Presumptive PTB

 Previously known with Osteoarthritis

 She has no history of previous hospitalization, blood transfusion. There were

no allergies to food and medications noted.

Family History

Both parents has a known history of CAD. One of her male siblings
died having colon cancer and her youngest sister has seizure disorder. Her third
child died 4 months ago due to heart attack. Patient denies other heredofamilial
disease such as hypertension, asthma, Pulmonary tuberculosis & psychiatric
disorders

Personal and Social History

Patient is a highschool graduate from Rosario National

Highschool in Batangas. She is 3rd among her 5 siblings. She lives in a two storey
semi-concrete house with 2 bedrooms, 2 windows, & 2 doors with 1 private c.r. She
lives together with her husband, 2 sons & daughter together with her 2 grandchildren.

She eats three times a day mostly fish and veggetables.

She drinks 1 cup of coffee or milk a day. She loves to eat candies & fruits especially
mango. She does not smoke or drink alcohol. She exercises by brisk walking around
the barangay every morning or whenever she goes to the market. She sleeps for 8
hours and wakes up early in the morning.
 Their source of water is from nawasa and electricity is
from meralco. Garbages are collected every wednesdays and fridays. They have no
pets in the house. Pests such as rats and cockroaches are present.

OB-GYNE HISTORY

OB Score:G4P4(4004)

Type of Place of Condition

Gravida Year Attendee Sex of Baby Complications
Delivery Delivery of Baby
G1 1978 NSD Hilot House Male Term, live None
G2 1979 NSD Hilot House Male Term, live None
G3 1981 NSD Midwife House Male Term, live None
G4 1982 NSD OB Hospital Female Term, live None

Menstrual History

Menarche 14 years old

Interval regular
Duration 3- 4 days
Amount 2-3
“katsa”; fully-soaked
Symptoms none
Menopause 53 y/o

REVIEW OF SYSTEM

General:
(-) Loss of appetite, (-) fever, (-) chills, (-) malaise, (-) easy fatigability, (-) weight loss

Integumentary

Patient’s skin in brown in color, fairly dry and generally warm.

Good skin turgor, mobility and elasticity.
(+) 4cmx5cm purplish black, dry, non scaly with irregular borders
with hypopigmented and hyperpigmented areas healing wound
and 0.5cm x0.5cm x0.1cm ulceration on the lateral aspect, dorsum
of the foot, left
(+) 3cmx6cm purplish black, dry, non scaly with irregular borders
healing wound and 1cm x 0.5cm x0.1cm ulceration on the lateral
aspect, distal third, left leg
(+) 3cm x 3cm dry, purplish black scaly healing wound lateral
aspect , distal third right leg
Head and Neck:
(-) eye pain (-) dizziness (-) ear discharge (-) tinnitus (-) epistaxis(-) hoarseness
(-) sorethroat

Respiratory
(-) dyspnea (-) cough (-) difficulty of breathing (-) hemoptysis (-) orthopnea

Cardiovascular System:
(-) edema, (-) cyanosis, (-) syncope, (-) orthopnea, (-) paroxysmal nocturnal dyspnea,
(-) neck vein distension, (-) palpitation
Gastrointestinal System:
(-) abdominal pain, (-) nausea, (-) vomiting, (-) diarrhea, (-) constipation, (-)
hematochezia, (-) melena, (-) dysphagia, (-)hematemesis, (-) abdominal
enlargement.

Genitourinary system:
(-) urinary frequency, (-) urgency, (-) dysuria, (-) incontinence, (-) polyuria, (-)
hematuria, (-) flank/suprapubic pain, (-) discharge

Musculoskeletal system:
(-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) muscle pain, (-) joint
pain, (-) weakness, (-) atrophy

Neuropsychiatric system:
(-) loss of consciousness, (-) paralysis, (-) numbness, (-) paresthesia, (-) speech
disorder, (-) tremors, (-) depression

Endocrine System:
(-) intolerance to heat and cold, (-) polydypsia, (-) abnormal growth

Hematopoietic System:
(-) bleeding, (-) easy bruising, (-) pallor

Physical Examination

GENERAL SURVEY

The patient is awake and alert, conscious and coherent. She is well-groomed,
calm, and responds appropriately to questions with appropriate facial expressions,
behavior, and mood. His body build is large, She has no apparent gross
 deformities. Patient is ambulatory with normal posture and gait. Not in
cardiopulmonary distress.

VITAL SIGNS
BP 130/80 mmHg CR:85 beats/min. RR: 19 cycles/min. TEMP: 36.9 C
spO2:97% Weight: 70 kg Height: 158 cm BMI: 27.2 kg/m2
waist circumference: 91 cm hip circumference: 87 cm

HEENT

Hair is black, well distributed, fine in texture, no flakes and no scaling. The skull
is symmetrical and has no deformities. No palpable mass, no tenderness were
noted. The face is symmetrical with appropriate affect. Skin is fair, moist and no
lesions. No involuntary facial movement noted.

Eyebrows are black and equally distributed.conjunctiva is pin, no lesion. The

sclera is white .Cornea is transparent, clear, no opacities, no foreign bodies. Pupils
are symmetrical; both are equally reactive to direct light reflex. No eyeball
resistance and tenderness. Fundoscopy was not done.

Ears are symmetrical and appropriate with the face of the patient, no deformities,
no lesions, and no tenderness. External auditory canal is patent; walls are pinkish
in color, no discharge.

The nose is symmetrical, found in the midline,. Flaring of ala nasi is absent.
Septum is at the midline. No paranasal sinus tenderness.

Lips are pinkish, moist, no lesions, no pigmentations noted. Buccal mucosa is

pink, moist, no lesions and no swelling. Tongue is at the midline upon protrusion
and retraction, mobile and the patient can move it without difficulty, no lesions,
no inflammation noted. The patient has incomplete set of teeth, no dental carries.
The the uvula is at the midline. Tonsils are small and pinkish. Posterior
pharyngeal wall is pinkish, no lesion, no swelling, and no exudates.

Neck is symmetrical, no deformity, No tenderness noted. Thyroid gland not

palpable, thyroid gland all raise upon swallowing, no mass, and no tenderness. No
neck vein engorgement and no lymphadenopathy noted.

Chest and Lungs

Skin is fair , no lesions. The thorax is elliptical, symmetrical without bony

deformities. No intercostal retractions, no bulging, no widening or narrowing of
ICS, no lagging of the chest during respiration. Patient’s breathing has regular
rhythm. No tenderness, no mass were noted, with symmetrical chest expansion.
Cardiovascular

Adynamic precordium. No bulging or depressions noted. Neck veins are not

distended. No thrills, heaves or lifts felt on palpation. No cardiac murmurs noted, For
the peripheral pulses, they are bilaterally palpable with equal amplitude and strength.

Abdomen

Upon Inspection, Abdomen is flabby , with no visible blood vessels noted , with
normoactive bowel sounds. Negative for direct and rebound tenderness, negative
for Psoas, obturator, rovsings sign.

Extremities

Nail beds are pink, no clubbing of fingers. No tenderness, no swelling and no nodules
of the hand and wrist. The patient can flex, extend, abduct, and adduct the hands and
wrist. The patient can perform pronation and supination of the forearm. Elbows are
symmetrical, no atrophy. No tenderness, no swelling. The patient can perform fully
the abduction, adduction, external and internal rotation of the shoulder joints. The
patient can perform plantar flexion, dorsiflexion, inversion and eversion of the foot.
No bipedal edema noted, eczema-like lesion present at left foot.

GENITALIA/ RECTUM:

Not assessed

Neurological Examination

Cerebral Function
 The patient is conscious and coherent. Speech is normal as to tone, volume,
speed and content, without any signs of slurring. Oriented to time, place and
person. He was able to follow simple and complex commands. Intact
immediate, recent, and remote memory.
 Cranial Nerves:

I: Intact, can identify smell on both nostrils

II: Both eyes visual acuity of 20/20 using newspaper
II & III: Pupils reactive to direct and consensual light stimuli
IV, V, VI: Can gaze at 6 cardinal directions
V: Sensory – with intact sensation on face
Motor – with good strength of temporal and masseter muscles
VII: Sensory – can recognized taste on the anterior 2/3 of tongue
 Motor – perform different facial expression with ease
VIII: Patient can repeat soft spoken words
IX & X: Uvula is in the midline. (+) gag reflex
X: (-) Voice hoarseness
XI: Can shrug shoulders against force
XII: Tongue is in the midline

Motor Testing
Upon inspection, no fasciculations, atrophy or hypertrophy noted. No involuntary
movements. Muscle tone is normal. Muscle strength is 5/5

Reflexes
Deep tendon reflexes are 2+ or normal. Negative for Babinski and Chaddock
reflexes.

Sensory Exam
Intact sensation for pain, crude touch, and postion sensation on upper and lower
extremities, both sides.

Meningeal Signs
Patient negative for Kernig and Brudzinski signs. No nuchal rigidity.

Salient features:

Age: 72 years old

Gender: Female
Bilateral knee pain, hip pain
Obese 1
occupation: market vendor

pertinent negatives:

(-) crepitus
(-) swelling
(-) erythema
(-) increase warmth
(-) palpable mass/knee cysts

Differential Diagnosis:
 RULE IN RULE OUT
GOUT Joint pains Small joint of big toe usually
Menopause affected (tophi)
Unknown blood uric acid
Unilateral
Rheumatoid Arthritis Female Autoimmune
Joint pains PCP and DIP are commonly
involved
Musculoskeletal StrainJoint pains Absence of previous injury
(MSS) Usually performs householdNo swelling
chores Absence of limitation in
range of motion

ASSESSMENT: Musculoskeletal disorder to consider Osteoarthritis Bilateral

knee; Eczematous Dermatitis 4cmx5cm lateral aspect, dorsum of the foot,
left,
3cmx6cm lateral aspect, distal third, left leg,3cm x 3cm lateral aspect , distal
third right leg;; Diabetes Mellitus Type 2; Dyslipidemia; Presumptive PTB;
Obese I; Myoma Uteri (2014)

PLAN :

Low Fat, low salt , diet

Advise patient to eat small frequent meals, more fruits and vegetables
Apply Hot compress both knee for 20 minutes to relieve mild-moderate
pain
Avoid lifting heavy objects
Get Adequate Rest and Sleep
Advise patient to do Low intensity aerobic exercises like walking 20-
30minutes daily
Daily wound care, body hygiene and avoid scratching the wound.
Avoid exposure to detergents and use mild soaps.
For BP monitoring and record
Continue oral maintenance medication:
Vildagliptin + Metformin(Galvumet) 50/500 mg/tab OD for Diabetes
Rosuvastatin 10mg/tab OD for Cholesterol
Fenofibrate 250mg/tab OD for Triglycerides
Diclofenac sodium 100mg/tab as needed for severe pain
Still for referral to a nutritionist for Diet plan
Still referral to Gyne for Myoma-Uteri