A FAMILY CASE PRESENTATION

by

Cebu Doctors’ University - College of Medicine

Group 6 Clinical Clerks

Von Bryan Fernandez

Ivan Justine Lim
Queenie Joie Canabe
Patrisha Tara Ignacio
Nesteen Marie Almirante
Marie Carmel Galan
Aira Jade Langcauon
Kim Marie Capilitan
Emmanuella Isah
Lloyd Delina

July 26, 2023

Group 7 - Family Case Presentation July 26, 2023

Clinical Clerks:
Von Bryan Fernandez, Ivan Justine Lim, Queenie Joie Canabe, Patrisha Tara
Ignacio, Nesteen Marie Almirante, Marie Carmel Galan, AIra Jade Langcauon, Kim
Marie Capilitan, Emmanuella Isah, Lloyd Delina

Clinical Preceptor:
Mr. Job “Boy” Sarmago

Resident Doctors:
Dr. Resnol Torres III
Dr. Margarito Maningo III

Department Head:
Dr. Charles Chloe Capute-Parilla

General Objective:
To discuss the family dynamics of the Zarco Family and address their family
issues and problems and be able to provide prompt interventions.

Specific Objectives:
- To conduct a comprehensive assessment and examination of the patient's
present health status and overall condition
- To apply effective family assessment tools to gain insight into the
dynamics, relationships, and functioning of the patient's family
- To employ Patient-Centered, Family-Focused, and Community-Oriented
Approaches to ensure holistic care and support for the patient and their
family
- To analyze the medical, psychological, social, and economic factors
influencing the patient, family, and community
- To formulate a feasible and relevant management plan that addresses the
specific needs of the patient and his family.

Scope and Limitations:

- The study focuses on the Zarco Family residing in Tongo, Brgy. Polog,
Consolacion Cebu.
- The assessment primarily covers the physical and social health of the
index patient, along with an examination of the family profile, structure,
development, function, dynamics, and the social determinants of health.
 - The formulated management plan takes into consideration the current
situation of the patient and the identified family issues.
- The findings are based on the knowledge and perception of the household
members within the Zarco family.
- The documentation process focused specifically on the index family, their
living conditions, and the characteristics of their community.

Family Identification
- The family was previously identified by Mr. Job Sarmago (Clinical
Preceptor) of Kauswagan Community Clinic and Health Center, and was
suggested by Dr. Charles Chloe C. Parilla (Community and Preventive
Medicine Chairman). They are aware of the index family's health situation
and living condition.
Consent Form:

KASAYORANG PAHIBALO NGA PAGTUGOT SA MGA MOAPIL

Titulo sa Kalihokan: Family Case Presentation

Mga Tig-interbyu: Von Bryan Fernandez, Ivan Justine Lim, Queenie Joie Canabe,
Patrisha Tara Ignacio, Nesteen Marie Almirante, Marie Carmel Galan, AIra Jade
Langcauon, Kim Marie Capilitan, Emmanuella Isah, Lloyd Delina

Pasiuna: Mga Level 4 nga estudyante sa Medicine gikan sa Cebu Doctors’ University,
magpahiluna ug interbyu kabahin sa inyohang pamilya. Kining maong interbyu
mahitungod kabahin sa inyong relasyon sa inyong mga miyembro sa pamilya, ug ang
sitwasyon diha sulod sa inyong pamilya. Kamo among gi imbitar sa pag-apil niining
interbyu. Sa dili pa kamo modesisyon, kung aduna pa kamoy mga pangutana o dugang
katin-awan, ayaw kamo pag-dumili sa pagduol o pagpangutana sa mga tig-interbyu.

Boluntaryo nga Pag-apil: Ang inyong pag-apil niining interbyu kay boluntaryo. Naa
kamoy tungod nga magdumili ug dili pagtubag sa mga pangutana o pag undang ug apil
niining interbyu.

Kadugayon: 2 ka oras ang gidugayon sa interbyu sa tibuok pamilya. Ang mga

estudyante mobisita sa barangay para personal nga ma interbyu ang mga miyembro sa
pamilya.

Risgo: Naay risgo na imong masinati sama sa dili komportable na pagtubag sa mga
pangutana kabahin sa inyong pamilya. Bisan pa niana, kaming mga tig-interbyu gusto
kining likayan. Bisag kanus-a, pwede ka mohunong ug participar niining kalihokan kung
dili ka komportable sa mga pangutana.

Benepisyo/Kaayohan: Ang mga impormasyon nga among makolekta magpabilin nga

kompidensyal para lamang niining kalihokan. Daghan kamo makat-onan kabahin sa
inyong pamilya.

Reimburso/Refund: Dili mo namo matagaan ug insentibo sa inyong pag-apil niining

interbyu. Apan kami mohatag kaninyo ug stipend ug gamayng groceries para sa inyong
gigahin nga oras sa pag-apil niining kalihokan.
Pagtago/Pagkakompedensyal: Ang mga record niining interbyu magpabiling hugot
kompidensyal. Ang mga resulta puwede lamang hisgutan sulod sa among hugpong nga
magtutuon. Tanang mga impormasyon nga among makuha giisip namo nga
kompidensyal ug gamiton lamang sa katuyuan aning kalihokan. Ang mga pagkatawo
magpabiling kompidensyal basi sa atong balaod. Ang mga nakolektang impormasyon
kay guntingon ug ilabay paghuman sa kalihokan.

Panag-ambit ug Resulta: Bisan unsa nga impormasyon nga imong mapaambit o

mahatag karon, dili mapaabot o maistorya sa ubang tawo gawas sa among hugpong
nga magtutuon.

Katungod sa Pagdili o Pag-atras/Balibad ug Di Pagpadayun: Dili ka pugson nga

moapil niini nga pagtuki. Kung dili nimu gusto, puwede ka mo-undang sa pag-apil sa
interbyu ug pagtubag sa mga pangutana bisan kanus-a nimo gusto.

Kinsa Pwede Tawagan: Kung naa mo mga pangutana, mahimong tawagan o textsan
si Mr. Von Bryan Fernandez, ang lider sa grupo niining kalihokan. Ang iyang numero sa
selpon kay 09176390815.

Sertipiko sa Pag-uyon

Akong nabasa ang mga impormasyon, o gibasa kini sa akoa. Naa koy kahigayunan sa
pagpangutana kabahin ani ug tanan natubag sa akong katagbawan. Boluntaryo ko na
motugot isip usa ka partisipante sa gihisgutang kalihokan.

Pirma sa Partisipante
 PATIENT-CENTERED APPROACH:

DATE AND TIME: 07/10/2023

SOURCE: Patient and Live-In Partner
RELIABILITY: 80%

General Data:
A.Z., 63 years old, male, Filipino, Roman Catholic, born on July 11, 1960 in
Consolacion, Cebu, currently residing in Tongo, Brgy. Polog, Consolacion, Cebu, was
referred to Kauswagan Community Clinic and Social Center for the 3rd time.

Chief Complaint: black tarry stool

History of Present Illness:

2 weeks from home visit, patient had dull epigastric pain, PS 6/10, and non
radiating. Nausea was noted but no associated vomiting episodes, continuous low
grade fever; Tmax: 38.2ºC. He took Multivitamins with Iron 350 mg/tab P.O. once a day.
Decreased appetite was noted with no cough, no headache and normal urination.

1 week from home visit, the patient had dull non radiating epigastric pain, a pain
score of 7/10 and associated with nausea, continuous low-grade fever; Tmax: 38ºC.
Body malaise seen, and black tarry stools noted. The patient was given Vitamin B
Complex. No cough and headache noted, and normal urination.

Patient was referred to Eversley Childs Sanitarium and General Hospital, and
advised admission after assessment by the Group 6 clinical clerks

Past Medical History:

Patient had a history of Gouty Arthritis in 2019. Patient had a motor vehicular
accident in 2020 together with his live-in partner in the north of Cebu at 3 pm in the
afternoon. He vomited blood and lost consciousness for a few minutes but refused to be
admitted. He had no weakness, headache, and dizziness after the accident. He had a
history of Bilateral Nephrolithiasis and Bilateral Renal Cortical Cyst in 2022. He has no
food and drug allergies and screening tests such as CBC, UA, Stool, ECG, chest x-ray,
SGPT/SGOT, BUN, blood uric acid, albumin, sodium and potassium were taken last
July 2, 2023. Results showed low hemoglobin, hematocrit, and high BUA.
Family Medical History:
The patient's father was a farmer from Leyte who was apparently healthy until he
died at the age of 90 years old. His mother was a housewife who also died at the same
age. His older brother is a 72 year old farmer from Leyte with good health. His 2nd
sibling, male, a 70 year old healthy businessman. His 3rd sibling is a 68 year old retired
female teacher from Leyte with good health. His 4th sibling, female, a 60 year old
housewife also with good health. Patient has a family history of gouty arthritis from the
paternal side but no known history of heredofamilial diseases such as diabetes,
hypertension, and cancer.

Personal and Social History

The patient graduated with a vocational course and worked as a government
contractual employee. He is a non-smoker, occasional alcohol drinker consuming 2
bottles per day, and has no history of illicit use of drugs. His diet included vegetables,
rice, dried fish, and canned goods.
He lives with his partner, who is a 58-year old housewife, hypertensive, and is
currently on maintenance of Losartan 50mg with poor compliance. They have a 13-year
old adopted son, who is a senior high school student with good health. Their house is
located uphill, which is made of light wood material and thin roofing. They live in a
1-bedroom house. Their bathroom is located outside the house, with a water-sealed
latrine. Electricity supply is from ROSCH, water from MCWD, garbage disposal is being
picked up by garbage collector once a week

This is a spot map of the Zarco Family’s residence located in Purok Tonggo,
Barangay Polog, Consolacion. It is approximately 230m from the Kauswagan
Community Clinic and Social Center. Their house is within a sanitary landfill and is a 10-
minute hike from the main road which has a steep and slippery walkway.
Road to their home:

Floor Plan:

The house is made of light wood material. It is not fire-proof and dust-proof.
Kitchen and Dining Area:

Bedrooms:
Toilet Area and Water source:

Patient’s family water source is from MCWD, and they buy mineral water for
drinking.

REVIEW OF SYSTEMS
General: Awake, alert, not in respiratory distress, weakness, fever, fatigue
Skin: (-) color change, (-) rashes, (-) sores, (-) non-healing wounds
Head: (-) headache, (-) dizziness, (-) lightheadedness
Eyes: (-) redness, (-) excessive tearing, (-) blurred vision, (-) double vision, (-)
eye pain
Ears: (-) earache, (-) discharges, (-) decreased hearing
Throat: (-) dysphagia, (-) odynophagia, (-) hoarseness, (-) bleeding gums, (-)
dental caries, (-) drooling
Neck: (-) lumps, (-) stiffness in the neck
Respiratory: (-) hemoptysis, (-) dyspnea, (-) wheezing, (-) cough
Cardiovascular: (-) chest pain, (-) palpitations, (-) murmurs
Gastrointestinal: (+) nausea, (-) vomiting, (+) black tarry stool, (-) constipation,
(+) abdominal pain, (-) food intolerance
Urinary: (-) frequency, (-) oliguria, (-) dribbling, (-) polyuria, (-) urgency, (-)
dysuria (-) hematuria, (+) kidney stones
Peripheral vascular: (-) leg cramps, (-) varicose veins
 Musculoskeletal: (+) joint pain & stiffness, (+) back pain, (+) gout arthritis in right
wrist, (+) arthralgia, (+) limited ROM
Neurologic: (+) numbness, (+) tingling of lower extremities

PHYSICAL EXAMINATION
General Survey
The patient was awake, conscious and coherent, non-ambulatory,
bedridden, with pale complexion, speech pattern was staggered. Body built was
ectomorph, nutritional status possible wasting with IBW of 45-55 kg, not in respiratory
distress.
Vital Signs
Blood pressure - 100/70 mmHg
Heart rate - 118 bpm
Respiratory rate - 25 cpm
Temperature - 38 C
O2 saturation - 98%
SKIN: Brown skin complexion, pallor, warm, good turgor and mobility, no noted
masses and lesion, no jaundice
HEAD: Normocephalic, symmetrical facial features, no gross deformities
EYES: Anicteric sclerae, pale palpebral conjunctivae, (+) direct and consensual
pupillary light reflex, (-) ptosis, (-) exophthalmos, (-) nystagmus, full range of motion of
extraocular muscles
EARS: Symmetrical with no deformities, (-) ear discharge
NOSE: Symmetrical with distinct borders, (-) nasal discharges
MOUTH: Lips are pinkish-brown, tongue is midline, pink oral mucosa, no oral
lesions
NECK: No masses or scars, no lymphadenopathies noted
CHEST AND LUNGS: Equal chest expansion, clear breath sounds on both lung
fields
CARDIOVASCULAR: No masses or lesions on the chest, distinct heart sounds
ABDOMEN: Flabby abdomen, normoactive bowel sounds, soft, nontender, no
palpable masses, (-) Murphy’s sign, (-) Rovsing’s Sign
BACK AND EXTREMITIES: No pressure ulcers noted, weak pulse on the both
lower extremities, grade II bipedal edema on both lower extremities. (+) loss of muscle
mass on both lower extremities

CRANIAL NERVE EXAMINATION:

CN I: Patient was able to recognise the smell of alcohol in both nostrils
CN II and III: (+) positive direct and consensual pupillary light reflexes on both
eyes
 CN III, IV, VI: (+) Extraocular movements
CN V: patient was able to clench teeth, with contraction of temporal and
masseter muscles and smile but with resistance,
CN VII: No facial asymmetry noted.
CN VIII: Patient listens and responds well on both ears
CN IX and X: No hoarseness of voice noted. (+) gag reflex,
CN XI: patient was unable to shrug shoulders against examiner's hands
CN XII:Tongue symmetric, no deviation from the midline during tongue
protrusion, uvula midline

Motor system:
ROM: Full ROM on the left upper extremities, limited range of motion on the right
upper extremity and on both lower extremities
Coordination: unable to stand on its own with support, non-ambulatatory
Motor Strength: LUE: 5/5, RUE: ⅗, LLE: ⅘, RLE: ⅘
Sensory System (via light touch):
Right Forearm: 2
Right wrist & hand: 2
Right thigh: 1
Right foot: 2
Left Forearm: 1
Left wrist and hand: 2
Reflexes: not done
Meningeal Signs: not done

SUMMARY OF PERTINENT FINDINGS

Risk Factors:
● Took NSAIDs for arthritis
● Former alcohol drinker
● Advanced age
History:
● Black Tarry Stool
● Gouty Arthritis (Right Wrist) - 2019
● Motor Vehicular Accident - 2020
● Bilateral Nephrolithiasis & Bilateral Renal Cortical Cyst - 2022
Physical Examination:
● On both lower extremities: weak pulse, Grade II bipedal edema,
loss of muscle mass, limited ROM
DIFFERENTIAL DIAGNOSES

Differential Rule In Rule out

● Gender ● (-) Family history

● Anemia ● (-) Exposure to
● Fatigue / Weakness radiation
● Pallor ● (-) No frequent
Multiple Myeloma ● GI bleeding - infections
Melena ● (-) Unexplained
● Kidney problems weight loss
(swelling in the legs) ● r/o via BM aspiration
● Nephrolithiasis (Ca) and biopsy
● Tingling, weakness
of the extremities
● Confusion

● Age >50 ● (-) Family history

● GI bleeding ● (-) Pruritus
(Melena) ● (-) Exposure to
● Anemia radiation
Essential Thrombocytosis ● Fatigue and ● r/o via BM aspiration
Weakness and biopsy
● Pallor
● Numbness/Tingling
in the extremities
● Gouty Arthritis

r/o via endoscopy or

● Age colonoscopy
● Melena
Colonic Angiodysplasia ● Anemia
● Fatigue/Weakness
● Upper abdominal
discomfort

● Age >50 /Male ● (-) Family History

● Diet - high in salt ● (-) Weight loss
Gastric Cancer ● Loss of appetite ● (-)Hematemesis
● Upper Abdominal ● r/o via endoscopy
Discomfort and biopsy
● Melena
● Anemia
 ● Fatigue/Weakness

● Age & Gender ● (-) Smoker

● Melena ● (-) Family History
Esophageal Cancer ● Anemia ● (-) Weight loss
● Fatigue ● (-) Dysphagia /
Odynophagia
● (-) Hematemesis
● r/o via endoscopy
and biopsy

IMPRESSION
1. Anemia secondary to Bleeding Peptic Ulcer
2. Gouty Arthritis
3. Bilateral Nephrolithiasis

FORMULATION

● History of NSAID use from gout arthritis & lower back pain.
● Long term NSAID use caused mucosal bleeding as manifested by anemia,
anorexia, epigastric pain & melena
● Presence of untreated nephrolithiasis contributed to the development of PUD
● The patient's demographics also contributed to the development of peptic ulcer
disease.
● History of gouty arthritis with consideration of the patient's diet and development
of poor kidney function contributed to the formation of tophi on the right wrist
● Presence of low grade fever, Tmax: 38ºC for 2 weeks, monoarticular pain, and
limited range of motion contributes to the diagnosis of Gouty Arthritis
● AKI was also considered due to the pre existing nephrolithiasis and the evidence
of a bipedal edema grade II not attributed to the CVS

MANAGEMENT
A. Diagnostic (Definitive)
a. Endoscopy
b. Ultrasound of the whole abdomen
c. Chest & Lumbosacral spine x-ray
d. Urea breath test
B. Diagnostic (Supportive)
a. Complete Blood Count
b. Urinalysis
c. Fecal Occult Blood Test
d. Blood Typing
e. BUN & Creatinine
f. Blood Uric Acid
 g. HBA1C
h. CRP, ESR
C. Pharmacologic Treatment:
a. Omeprazole 40mg, 1 tablet once daily
b. Paracetamol 500 mg, 1 tablet every 4 hours as needed for fever >38C
c. Multivitamins + B complex, 1 tablet once daily
D. Non-Pharmacologic Treatment:
a. Blood Transfusion of 3 packs of PRBC
b. Health Teaching on the red flags of Peptic Ulcer Disease
c. Timely referral for possible danger signs of an Upper Gastrointestinal
Bleed
d. Encourage balanced diet with low salt intake of 2.3g per day and healthy
protein sources, LOW purine diet by lessening consumption of beans,
nuts, internal organs, and canned goods
e. Lifestyle modification through alcohol avoidance
f. Advised to increase fluid intake to 7-8 cups per day
g. Advised to practice oral hygiene

REFERRALS

● Upper GI Endoscopy sponsorship

● Further evaluation by a neurologist
● Follow up by a nephrologist for his bilateral cortical cyst
● Rheumatologist referral for further evaluation of his arthritis
● Rehabilitative Medicine enrollment for muscle and joint strengthening
○ Physical therapy for strengthening muscles
○ Occupational therapy for ADLs

FINAL IMPRESSION
1. Anemia secondary to Upper GI bleeding probably secondary to PUD
2. Gouty Arthritis
3. Bilateral Nephrolithiasis

DISCUSSION
A. PEPTIC ULCER DISEASE
a. ANATOMY
- Gastric epithelial lining consists of rugae
- 75% of gastric glands are found within the oxyntic mucosa
- Highly specialized tuft cells - important in regulating gastric acid
secretion
- Parietal cell (oxyntic cell) - found in the neck or isthmus or in the
oxyntic gland
b. DEFINITION
- A peptic ulcer is defined as disruption of the mucosal integrity of the
stomach and/or duodenum leading to a local defect or excavation
due to active inflammation
c. EPIDEMIOLOGY
 - Latest WHO data published in 2020 - Peptic Ulcer Disease Deaths
in Philippines reached 6,865 or 1.02% of total deaths
- The age adjusted Death Rate is 9.95 per 100,000 of population
ranks Philippines #12 in the world
- The death rates, need for surgery, and physician visits have
decreased by >50% over the past 30 years.
- GUs tend to occur later in life (age 60s)
- More than one-half of GUs occur in males and are less common
than DUs
d. ETIOLOGY
- H.Pylori
- Accounts for the majority of PUDs
- Plays a role in the development of gastric
mucosa-associated lymphoid tissue (MALT) lymphoma and
gastric adenocarcinoma
- NSAID-Induced
- Established risk factors include advanced age, history of
ulcer, concomitant use of glucocorticoids, high dose NSAIDs,
multiple NSAIDs, concomitant use of anticoagulants or
clopidogrel, and severe or multisystem disease
e. RISK FACTORS
- H.pylori infection
- NSAID use
- Chronic Obstructive Pulmonary Disease
- Chronic Renal INsufficiency
- Tobacco use
- Older age
- Coronary Artery Disease
- Alcohol use
- African-American race
- Obesity
- Diabetes
f. PATHOPHYSIOLOGY
i. H. pylori
- Campylobacter pyloridis are commonly found in deeper
portions of gastric mucosa which normally attaches to gastric
epithelium but does not invade cells
- It is capable of transforming into a dormant state which
facilitate survival
- H. pylori encodes thousands of proteins, which are essential
determinants of H. pylori-mediated pathogenesis and
colonization
- It is also capable of producing urease, which is an important
step in alkalinizing the gastric pH
- This could lead to mucosal injury and ulceration
ii. NSAID-induced
 - Prostaglandin maintains gastroduodenal mucosal integrity
and repair, and interruption of prostaglandin synthesis by
NSAID intake can impaired mucosal defense, thus,
facilitating mucosal injury
- Initiation of NSAID-induced mucosal injury starts with
neutrophil adherence and release of subsequent
proinflammatory mediators such as TNF and leukotrienes
g. CLINICAL MANIFESTATIONS
i. History
- Abdominal pain
- Epigastric pain - burning or gnawing discomfort; ill-defined,
aching, hunger pain
ii. Physical Examination
- Epigastric tenderness
- Tachycardia / orthostasis - dehydration or active blood loss
- Severely tender/boardlike abdomen - perforation
- Succussion splash - gastric outlet obstruction
iii. Duodenal Ulcer
- Occurs 90 min to 3 h after a meal
- Frequently relieved by antacids or food
- Pain wakes patient from sleep = most discriminating
symptom
iv. Gastric Ulcer
- Precipitated by food
- Nausea and weight loss more common
h. DIAGNOSTIC TESTS
- CBC and Iron studies
- Liver function tests
- Amylase and Lipase
- Serum gastrin and gastric acid analysis
- Screening for NSAIDS (blood or urine)
- Barium Study
- Upper GI Endoscopy
i. MANAGEMENT
i. Non-Pharmacologic:
- Opt for the lowest effective dose of NSAID
- Avoid or limit alcohol intake
- Eat a fiber rich diet
- Cut down on coffee and carbonated beverages
- Reduce stress with relaxation techniques
- Avoid spicy foods
ii. Pharmacologic:
 iii.
Surgical:
- Elective - for medically refractory disease (exceedingly rare)
- Urgent/emergent - for an ulcer-related complication (more
often indication)
- Hemorrhage: MC ulcer-related complication
- Others:
- Peritoneal perforation
- Gastric outlet obstruction
j. PREVENTION
- Talk to your doctor about alternatives to NSAID medications
- Discuss precautionary measures with your doctor if NSAID should
be continued
- Quit smoking
- Drink alcohol in moderation
- Drink and use clean water
- Proper handwashing
 FAMILY-FOCUSED APPROACH

Family IllnessTrajectory
Stage 2: Reaction to the diagnosis
The patient’s condition has made an impact on the family. The family members
were informed of the patient’s condition, its causes, and the importance of its
management to prevent further complications

A. GENOGRAM
 B. FAMILY MAP

C. FAMILY LIFELINE

Year Age Life Event Severity of

Illness

1972 12 Elementary Graduation

1976 16 High School Graduation

1984 24 Marriage

1986 26 Birth of 1st child

1989 29 Birth of 2nd child

1993 33 Birth of 3rd child

2017 54 Shared a house with his partner

2019 59 Diagnosed with Gouty Arthritis ….

2020 60 Motor Vehicular Accident …….

2022 62 Diagnosed with Bilateral Nephrolithiasis and Bilateral …………
Renal Cortical Cyst

D. FAMILY CYCLE

● The Zarco family falls under the stage of family with adolescents which
starts when the first child reaches adolescent age (12 yo).
● The family’s adopted child is 13 years old and is currently in high school.
● This stage has 3 hallmarks which are the changes in the balance of
responsibility, marked shifts in the intensity of the relationship, and surge
of exchange with the community at large.
● E.G.,the live-in partner of the patient continues to be the caretaker while
J.L, the adopted son helps out in the household chores and caring for the
patient.

E. FAMILY RESOURCES

Members 18 y/o Occupation Additional Total Income

and above

A.Z. Unemployed None 0

E.G. Unemployed None 0

Mother of J.L. Php 8,000/month

 F. FAMILY EXPENDITURE

Food Php 3,000

Electricity Php 2,000

Water Php 500

Medicine Php 3,000

Education Php 1,800

Total Php 7,800

G. FAMILY APGAR

July 2023 August 2023

A.Z (Patient) Alway Sometim No (0)

s (2) es (1)

A I am satisfied
that I can turn to
my family for
✔
help when
something is
wrong

P I am satisfied
with the way my
family talks over
things with me ✔
and share
problems with
me

G I am satisfied
that my family
accepts and
supports my
✔
wishes to take
on new
activities for
directions

A I am satisfied ✔
 July 2023 August 2023

with the way my

family
expresses
affection and
responds to my
emotions such
as anger,
sorrow, and
love

R I am satisfied
with the way my
family and I ✔
share time
together

Total: 3 - Severely dysfunctional family

A.Z. How do you get along?

Who lives in your house?

Name and Age Sex Well Fairly Poor

Relationship

Elma 70 Female ✔
Gabucan
(Live in
Partner)

Joseph 13 Male ✔
Francis
Luchavez

If you don’t live with your family, list the How do you get along?
persons whom you can turn to for help

Benjie 40 Male ✔
(brother)

July 2023 August 2023

E.G. (Live in Alway Sometim No (0)

 Partner) s (2) es (1)

A I am satisfied that
I can turn to my
family for help ✔
when something
is wrong

P I am satisfied with
the way my family
talks over things ✔
with me and share
problems with me

G I am satisfied that
my family accepts
and supports my
✔
wishes to take on
new activities for
directions

A I am satisfied with
the way my family
expresses
affection and
✔
responds to my
emotions such as
anger, sorrow,
and love

R I am satisfied with
the way my family
✔
and I share time
together

Total: 2 - Severely Dysfunctional family

E.G. How do you get along?

Who lives in your house?

Name and Age Sex Well Fairly Poor

Relationship

Abondio 63 Male ✔
Zarco
(Live in
Partner)

Joseph 13 Male ✔
Francis
Luchavez

If you don’t live with your family, list the How do you get along?
persons whom you can turn to for help

none

July 2023 August 2023

J.L. Alway Sometim No (0)

s (2) es (1)

A I am satisfied that
I can turn to my
family for help ✔
when something is
wrong

P I am satisfied with
the way my family
talks over things ✔
with me and share
problems with me

G I am satisfied that
my family accepts
and supports my
✔
wishes to take on
new activities for
directions

A I am satisfied with
the way my family
expresses
affection and
✔
responds to my
emotions such as
anger, sorrow, and
love

R I am satisfied with ✔
 the way my family
and I share time
together

Total: 6 - Moderately dysfunctional family

J.L. How do you get along?

Who lives in your house?

Name and Age Sex Well Fairly Poor

Relationship

Elma 70 Female ✔
Gabucan
(Guardian)

Abundio 63 Male ✔
Zarco
(Guardian)

If you don’t live with your family, list the How do you get along?
persons whom you can turn to for help

Josephine 47 Female ✔
(biological
mother)

FAMILY APGAR SUMMARY

July 2023 August 2023

E.G.
Z.A J.L.
(Live in
(Patient)
Partner)

Adaptat 0 0 1
ion

Partner 0 0 1
ship

Growth 1 1 2

Affectio 1 1 1
n
Resolve 1 0 1

Total 3 2 6

Averag
e 4 (Moderately Dysfunctional family)

H. SCREEM-RES

July 2023 August 2023

A.Z (Patient) Strong Agree Disagr Stron

ly (2) ee (1) gly
agree disagr
(3) ee (0)

S We help each ✔
other in our
family. We are
helped by
friends and
other
members of
the
community.

C Our culture ✔
gives our
family
strength. A
culture of
helping and
cooperation in
our
community
helps the
family.

R Our faith and ✔

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

E Our family’s ✔
savings are
adequate for
our needs.
Our family’s
income is
adequate for
our needs.

E Our ✔
education/kno
wledge is
adequate to
understand
information
about the
illness. Our
education/kno
wledge is
sufficient for
us to take
care of our
sick patient.

M It is easy to ✔
access
medical help
in our
community.
We are
helped by the
doctors,
nurses, and
healthcare
workers.

Total: 9 - Moderately Inadequate Family Resources

July 2023 August 2023

E.G. (Live Strong Agree Disagr Stron

in Partner) ly (2) ee (1) gly
agree disagr
 (3) ee (0)

S We help ✔
each other in
our family.
We are
helped by
friends and
other
members of
the
community.

C Our culture ✔
gives our
family
strength. A
culture of
helping and
cooperation
in our
community
helps the
family.

R Our faith and ✔

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

E Our family’s ✔
savings are
adequate for
our needs.
Our family’s
income is
adequate for
our needs.

E Our ✔
education/kn
 owledge is
adequate to
understand
information
about the
illness. Our
education/kn
owledge is
sufficient for
us to take
care of our
sick patient.

M It is easy to ✔
access
medical help
in our
community.
We are
helped by
the doctors,
nurses, and
healthcare
workers.

Total: 8 - Moderately inadequate Family Resources

July 2023 August 2023

J.L. Strong Agree Disagr Stron

ly (2) ee (1) gly
agree disagr
(3) ee (0)

S We help ✔
each other in
our family.
We are
helped by
friends and
other
members of
the
community.
C Our culture ✔
gives our
family
strength. A
culture of
helping and
cooperation
in our
community
helps the
family.

R Our faith and ✔

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

E Our family’s ✔
savings are
adequate for
our needs.
Our family’s
income is
adequate for
our needs.

E Our ✔
education/kn
owledge is
adequate to
understand
information
about the
illness. Our
education/kn
owledge is
sufficient for
us to take
care of our
sick patient.
M It is easy to ✔
access
medical help
in our
community.
We are
helped by
the doctors,
nurses, and
healthcare
workers.

Total: 9 - Moderately Inadequate Family Resources

SCREEM-RES SUMMARY
August 2023

A.Z. E.G. (Live J.L.

(Patient) in Partner)

S 1 1 1

C 2 2 2

R 2 2 2

E 1 0 2

E 1 1 0

M 2 2 2

Total 9 8 9

Averag
e 8.6 (Moderately Inadequate Family
Resources)

I. ST. FRED METHOD

Family Structure: Blended Family

Roles of Family Members

Index Patient: Abondio Zarco
Breadwinner: Mother of Joseph Francis
 Decision-maker: Elma Gabucan
Caregiver: Elma Gabucan

Rules and Boundaries:

Overt:
● Joseph Francis should immediately go home after school.

Covert:
● Elma Gabucan is responsible for taking care of Abondio Zarco and Joseph
Francis.
● Joseph Francis helps in taking care of Abondio Zarco and also does
household chores.

Transactional Pattern:
Triangulation:
● Decision making in the family is made by Elma Gabucan. However,
medical decisions regarding Abondio Zarco are made by his children.

Coalition and Closeness:

● Conflict between Elma Gabucan and the children of Abondio Zarco arises
mostly because of financial issues and the medical decisions of their
father.
● Joseph Francis has a good relationship between Elma, his guardian, and
Abondio Zarco.

Resonance Mapping
The patient, Elma Gabucan and Joseph Francis have a good relationship with
each other. Elma Gabucan and Abondio Zarco’s children have a conflict due to
financial issues and medical decisions.
J. ECOMAP

K. SMILKSTEIN DIAGRAM
 L. FAMILY DIAGNOSIS
Structure - Blended Family
Life Cycle - Couple with Adolescents
APGAR Score = 4 (Moderately dysfunctional family)
SCREEM-RES = 8.6 (Moderately inadequate family resources)
Smilkstein Cycle of family function = Family in Functional Disequilibrium
Family Illness Trajectory - Stage 2 (Reaction to Diagnosis)

M. FAMILY WELLNESS PLAN

Family Problems Goal of Care Intervention
Member Identified

A.Z. 1. Physical 1. To safely 1. To enroll for leg

63/M (Index limitations increase level of and foot
Patient) 2. Medical physical activity exercises c/o
Needs and develop a physical
3. Hygiene more active therapists
Needs lifestyle 2. To enroll to
4. Feelings 2. To provide relief Person with
of and comfort to Disabilities
isolation, patient’s (PWD) Program
being a medical needs 3. Provide
burden to 3. To observe assistance for his
the family, proper hygiene follow-up
and fear practices check-ups to
of death 4. To address sustain
emotional and compliance
social needs 4. Educate and
encourage family
members on
proper hygiene
by teaching
proper
handwashing and
oral care.
5. Provide
counseling or
refer to a
psychologist to
help understand
& communicate
patient’s needs
and boundaries
6. Encourage family
members to visit
 or provide
web-based
support via video
calls to provide
opportunities for
interaction

E.G. 1. Care for 1. To provide a 1. Teach and assist

58/F (Index the ill proper way to her how to do
Patient’s 2. Unemplo assist her proper medical,
Live-In yment partner’s hygiene care and
Partner) 3. Financial medical, nutrition and
Problem hygiene and assistance to her
nutrition needs. partner
2. To have another 2. Invite to
source of livelihood
income at home programs in
while she is Kauswagan
looking after his
partner.

J.L., 1. Care for 1. To provide a 1. Teach and assist

13/ M the ill proper way to him how to do
(Index 2. Hygiene assist his proper medical,
Patient’s Needs father’s medical, hygiene care and
Foster Son) hygiene and nutrition and
nutrition needs. assistance to his
2. To observe father
proper hygiene 2. Educate and
practices encourage family
members on
proper hygiene
by teaching
proper
handwashing and
oral care.
 COMMUNITY-ORIENTED APPROACH

A. SCREEM ANALYSIS

SCREEM RESOURCES PATHOLOGY

Social ● Patient and family ● The patient cannot

members interact with
their neighbors and
relatives
move and interact
with neighbors freely
● Family has conflict
between live in
partner, patient and
children of the patient

Cultural ● Family practices such as

celebrating Christmas,
New Year, and Fiestas are
practiced by the patient
and his family.

Religious ● The patient is a Roman

Catholic and has a good
relationship with God

Educational ● Patient is a graduate of

Vocational Training
● The patient’s adopted son
is attending high school in
a public school nearby

Economic ● The patient and his

● Index patient’s mother is live in partner are
working as a garbage both unemployed
collector ● Finances are not
enough for their
day-to-day and
medical needs
● No flexibility for other
needs

Medical Kauswagan Community Limitation in finances to

Center sends in Medical acquire and utilize
Clerks and Physical medical check-ups,
Therapists Interns to medications, and
 assess the patient. diagnostic
interventions needed.

B. EPIDEMIOLOGIC TRIAD

C. COMMUNITY BASED MANAGEMENT

ISSUES GOAL PROPOSED RESPONSIBLE

ACTIVITY AGENCY /
SECTOR

Low To encourage Livelihood Kauswagan

income-generating livelihood program programs and Community Clinic
source and use of income generating and Social Center,
resources of the activity, Pantawid DSWD, Barangay
community to Pamilyang Pilipino Programs
provide income Program

Unbalanced diet Educate and Feeding Program Kauswagan

encourage on Brochures from Community Clinic
adapting a healthy Barkadahan and Social Center,
lifestyle and a well meeting Barangay Health
balanced diet Volunteers
 D. SOCIAL DETERMINANTS OF HEALTH

SOCIAL COMMUNITY IMPACT TO INTERVENTION

DETERMINANT STATUS FAMILY

Economic Stability ● Limited job ● Inability to ● Encourage

opportunities provide and live in
due to the sustain partner to
level of medical participate in
education needs and livelihood
● Employment/ attained and expenses programs in
Work opportunities such as Kauswagan
● Food in the area. medication, Community
Security Lack of a job hospital Clinic and
and income admissions assist the
cause and family in
financial checkups. registering
constraints Inability to for various
in the family provide all government
● Lack of the daily assistance
funds to needs and programs.
purchase expenditures Encourage
healthier for the her to find
food which family. other
are essential ● Shortage of sources of
for food and income,
development lack of such as
and growth nutrients backyard
of family causes gardening
imbalanced and selling
nutrition harvested
products.
● Assist the
family in
registering
for various
government
assistance
programs
like
Pantawid
Pamilyang
Pilipino
Program and
 Social
Pension for
Indigent
Senior
Citizens

Health Care Access Kauswagan Free access to Continue

and Quality Community Clinic is healthcare services participation as
readily accessible and medications patient for timely
for the patient house visits.
wherein Medical
clerks and Physical
Therapy interns
from Kauswagan
Community Clinic
regularly visit for
free rehabilitation,
physical
examination and
follow up check ups
alongside free
maintenance
medicine from
health center

Neighborhood and
built environment ● Steep & ● Difficulty in ● Establish
1. Exposure to slippery transporting strong
hazards climb to the basic needs rapport with
environment house. and in neighbors to
2. Housing, ● Prone to fall transport in seek
basic accidents cases of assistance in
amenities, ● House is emergencies cases of
environment made of light ● Patient’s emergencies
wood difficulty in ● Establish a
material ambulation proper path
● House is far mixed with from home
from the the uneven to road via
main road terrain is a cement or
● Water risk factor for concrete for
source and falls and easier travel
styrofoam accidents access
water ● Prone to ● Ask live-in
containers, damage due partner to
which are to natural reach out to
 not always calamities community
covered, are and fire for improved
outdoors." accidents. housing
● Toilet is ● The family conditions.
outdoors has difficult Educate on
with no toilet access to fire safety
cover and no the main and proper
connected road. sanitation.
water source ● Increased ● Establish a
to the toilet. risk of proper path
● Bathroom infection and from home
and water illness due to to side road
supply are increased via cement
outdoors risk of or concrete
with no roof contaminatio for easier
and proper n with algae travel
flooring and bacteria access.
and ● Change the
increased styrofoam
risk of storage
dengue due water
to open container to
stagnant a plastic one
water with a cover.
containers Educate on
as breeding water
grounds for storage and
mosquitoes. dangers of
stagnant
water,
mosquito
breeding
sites, and
dengue.
● Advise
live-in
partner to
add a toilet
cover to the
toilet.
Educate on
proper
sanitation.
● Advise
live-in
partner to
 install walls
with the use
of concrete.

Social and
Community Context ● His family ● His limitation ● Encourage
rarely visits of movement clerks and
1. Social in times of makes it family
Support via hardship hard for him members to
socialization ● Family is to socialize visit the
2. Social unreliable with other family from
support via when it people. time to time
communicati comes to ● Limitation of ● "Encourage
on communicati movement family to
3. Social ng with him limits travel communicat
isolation and and e with him
4. Financial supporting limitation of more,via
and medical him amount of visitation or
problems in ● Social data and even through
family isolation of load owned call, text,
self and limits and social
family due to socialization media.
living in a with other Encourage
remote area. people. the family to
● Financial Family is join
and medical inconsistent barkadahan
problems in offering meetings
cause rifts in help and and seek
the family support. support from
● Feelings of community
neglect members."
● Inability to ● Encourage
communicat family to visit
e problems and spend
within the time with the
family. patient
● Encourage
family to
communicat
e
empathetical
ly and
openly about
 medical
needs and
expenses
and other
problems in
the family.

E. PLACE OF ORIGIN, RESIDENCE, ETHNICITY

Index Patient Father Mother

Place of Origin Hilongos, Leyte Hilongos, Leyte Hilongos, Leyte

Residence Cabangahan,
Consolacion

Ethnicity Filipino Filipino Filipino

F. ENVIRONMENTAL SANITATION
They buy mineral water as a source for drinking water, and VECO for their
source of electricity. Their garbage is being picked up by the garbage collector once a
day.

G. HEALTH CENTER AND OTHER RESOURCES

Kauswagan Community Health Clinic and Social Center, Eversley Childs
Sanitarium and General Hospital, Consolacion Fire Department, Consolacion Police
Department.

H. COMMUNITY’S EFFECT ON PATIENT’S ILLNESS

The patient’s neighbors and friends are always willing to help when assistance is
required.

I. PATIENT’S ILLNESS’ EFFECT ON THE COMMUNITY

Due to his inability to ambulate, the patient lives a sedentary lifestyle with little to
no physical activity. The patient is unable to engage in activities appropriate for his age
due to his limitation of movement and illness.

J. COMPARE EPIDEMIOLOGIC PICTURE

The patient’s condition has greatly affected his lifestyle. He is unable to perform
activities of daily living independently, including grooming, toileting, and preparing own
food. The patient has become dependent and fully relies on his live-in partner and foster
son for support and assistance in his activities.
DOCUMENTATION
 RECOMMENDATIONS

1. Facilitate Upper GI endoscopy test and Lumbosacral X-ray

2. Refer for further evaluation of neurologist, nephrologist for his bilateral
nephrolithiasis and cortical cyst, and rheumatologist for his gouty arthritis.
3. Continue leg and foot exercises c/o physical therapists
4. Continue counseling of entire family
5. Continue proper hygiene and diet
6. Facilitate registration of Elma Gabutan in Livelihood Program of Kauswagan
7. Facilitate enrollment of Zarco Family in the Pantawid Pamilyang Pilipino Program
 ACKNOWLEDGEMENT
Our sincerest and heartfelt gratitude to:
A. Zarco Family
B. Dr. Enrico B. Gruet and Dr. Charles Chloe Parilla
C. Dr. Jan Maningo, Dr. Phoebe Letaba, and Dr. Resnol Torres III
D. Sir Boy Sarmago and Ma’am Marilyn Reuyan
E. Cebu Doctors’ University RS Physical Therapy Department
References:
1. Harrison’s Internal Medicine Textbook 21st ed
2. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 10th ed