To present a case of G.J.

A, diagnosed with:

GENERAL
OBJECTIVE 1 Pleural effusion, left secondary to PTB

2 PTB bacteriologically confirmed

3 T/C T3 spondylitis
MEMBERS Joseph Joshua Ngushual
Luxsamon Wonglimkittigul
Darlen Uyangoren
Anunya Songrum
Santi Rakpor
Tapnaree Omkew
Nicharee Sutthiprapha
Saleh Almustaneri
Musa Mohammed Mancha
Manasseh Mbilewa
Yunti Wang
SPECIFIC
OBJECTIVE

1. To present the medical scenario and clinical discussion of the index case
2. To implement a medical plan of care for the index patient and the family within the
constrictions of the available resources of the family
3. To assess the family profile and family dynamics of the family using various family
assessment tools
4. To assess the impact of the illness to the family
5. To create a family wellness plan for each member and the family as a whole
6. To assess the effects of the entry of the resident in to the family cycle
TABLE OF 1 Patient's Data

CONTENT 2 Case Discussion

CompetitiFamily Profile, Structure,

3 and Function

4 Medical and Family Diagnosis

Patient’s Data
PATIENT’S
DATA
CC: Dyspnea
General data

G.J.A, 31 years old, Female, Single, Filipino,

Christian, born on Oct 21, 1991 currently residing in
Almers Compound Tabok, Mandaue city, Cebu
admitted for the first time in Vicente Memorial
Medical Center April 10, 2023.
HPI
2 years PTA, patient had occasional lower back pain radiating to the left upper
abdomen. No consult done, no medications taken. Condition was tolerated.
2 weeks PTA, patient had onset of nonproductive cough with whitish sputum
associated with on and off febrile episodes, Tmax 39C with night sweats, and (+)
weight loss.
1 week PTA,still cough now associated with dyspnea thus sought consult at OPD and
was advised for TB work up where sputum gene Xpert was positive for MTB. Due to
worsening of condition prompted admission.
FH
Paternal: (+) diabetic, (-) dyspnea
Maternal: (-) hypertension
(-) other heredofamilial diseases
PSH
Patient is non alcoholic and non smoker. No use of illicit drug. No food and drug
allergies.
PE
Height: 150 cm
Weight: 50 kg
BMI: 33.3 kg/m2

(4/17/23)
Examined awake and in respiratory distress with the following vital signs:
Temp: 36.6 C
BP: 120/70
HR: 82
RR: 24
O2Sat: 99%

Skin: warm to touch, good skin turgor

HEENT: normocephalic, pink palpebral conjunctiva, aniteric sclerae
C/L: (+) dyspnea, equal chest expansion
CVS: (-) murmur, adynamic precordium, distinct heart sounds
Abdomen: soft, flat, non tender, NABS
Extremities: SPP, CRT <2 sec
LABS
(4/12/23)
FBS 68 mg/dL (L)
Total cholesterol 113 mg/dL
Triglycerides 126 mg/dL
HDL 19 mg/dL (L)

(4/14/23)
Sodium 135.70
Potassium 2.66 (VL)
Chloride 102.30
Ionized calcium 1.02 (L)

Blood urea nitrogen 9 mg/dL

Creatinine 0.41 mg/dL (L)
Phosphorus 3.50 mg/dL
Magnesium 1.69 mg/dL
(4/15/23)
RBS 113
LDH 269 (H)
Total protein (L)

(4/17/23)
SGOT/AST 33
Total bilirubin 0.5
Direct bilirubin 0.24 (H)
Indirect bilirubin 0.26

Gene Xpert (4/14/23)

> Specimen: sputum
> Visual appearance: Mucoid
> Lab diagnosis: MTB detected high; Rifampicin resistance not detected
Cell count/ Body fluids result (4/15/23)
> Body fluids
>> specimen - pleural fluid
>> Color - brown
>> Transparency - turbid
>> Approximately volume - 40ml
> Automated cell count
>> WBC- BF - 44.382
>> RBC- BF - 0.062
> Differential count
>> Mononuclear - 38.50
>> Polymorphonuclear - 61.50
Microscopy results (4/17/23)
>> gram stain result
>> PUS cells = < 25
>> Epithelial cells = < 25
>> predominant organism:
>> gram (+) cocci in clusters = rare
>> gram (+) cocci in pairs = rare
>> gram (-) bacilli = rare

Sputum microscopy results: Salivary (4/17/23)

X-Ray report (3/24/23)

> Chest PA
>> Moderate left pleural effusion
> Thoracolumbar
>> Suspicious decrease vetebral height, T7-T10. Suggest CT correlation.
IMPRESSION
?- TINA
 CASE DISCUSSION
Pleural effusion:
- present when there is an excess quantity of fluid in the pleural space.
- may develop when there is excess pleural fluid formation or when there is decreased fluid removal by the lymphatics.
- chest imaging to diagnose its extent.
- Chest ultrasound can evaluate for suspected pleural effusion.
Transudative V.S. exudative pleural effusions
- LDH and protein levels in the pleural fluid.
Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none:
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH more than two-thirds the normal upper limit for serum

If a patient has an exudative pleural effusion, the following tests on the pleural fluid should be obtained:
- description of the appearance of the fluid
- glucose level
- differential cell count
- microbiologic studies
- cytology.
Tuberculous Pleuritis:
most common cause of an exudative pleural effusion is tuberculosis.
Tuberculous pleural effusions usually are associated with primary TB.
Patients with tuberculous pleuritis present
- fever
- weight loss
- dyspnea
- pleuritic chest pain.

Diagnosis
- established by demonstrating high levels of TB markers in the pleural fluid
- established by culture of the pleural fluid, needle biopsy of the pleura, or thoracoscopy.
MANAGEMENT:
(4/17/23 2:30PM)
> continue monitoring
> continue current medication
> I & O q shift
> follow up cell count, cell cytology, gene Xpert (pleural fluid)
> repeat CBC, BUN, Creatinine, electrolyte, magnesium,
phosphorus, chest x ray
PHARMACOLOGIC
MANAGEMENT
1. Salbutamol + Ipratropium Q6H
2. Acetylcysteine 600mg/tab, 1/2 tab + 50 cc water TID
3. HRZE tab, 3 tabs OD PO before breakfast
4. Ecoxaparin 0.4cc SC OD
5. KCL tablet, 2 tabs TID PO*4 days
6. Lactulose 30ml OD HS PO
7. Clindanmycin 600mg IV Q8H
8. Paracetamol 30mg IVTT for temp > 38C Q6H
9. Vitamin B complex tablet
 BRAND A

Brand Review and

Attributes
Presentations are communication tools
that can be used as demonstrations,
lectures, speeches, reports, and more. It
is mostly presented before an
audience. It serves a variety of
purposes, making presentations
powerful tools for convincing and Cia Rodriguez
teaching. CEO
 1 Nuclear Family

2 Single Parent Family

TYPE OF
FAMILY 3 Extended Family

STRUCTURE
4 Childless Family

5 Step Family

6 Grandparent Family

7 Unconventional Family
GENOGRAM
 Stage I
Unattached
Young Adult

Stage VI Stage II
Family in Later The Newly
Years Married Couple

Stage V Stage III

The Family With
Launching Family
Young Children

Stage IV
The Family With
Adolescents
FAMILY MAP
FAMILY APGAR I
Family APGAR M.L.

A Adaptation to Crisis 1

P Partnership on decision making 1

G Growth potential 2

A Affection 2

R Resolve to share resources 2

Total 8

Interpretation Highly functional

 BRIEF SCREEM FAMILY RESOURCES SURVEY (BRIEF SCREEM-RES)
– FILIPINO

Matinding Hindi
Sumasang Matinding Hindi
Kapag may nagkakasakit sa aming pamilya ... Sumasang- Sumasang
- ayon Sumasang- ayon
ayon - ayon

S Kami ay nagtutulungan sa isa’t isa sa aming pamilya.

Ang kultura ng pagtutulungan at pagmamalasakit sa aming

C
komunidad ay nakatutulong sa aming pamilya

Natutulungan kami ng aming mga kasamahan sa simbahan o

R
mga grupong relihiyoso

Sapat ang naipong pera ng aming pamilya para sa aming mga

E
pangangailangan

E Sapat ang aming kaalaman upang maalagaan ang may sakit.

M Madaling makakuha ng tulong medikal sa aming komunidad.

Total score 12 - moderately inadequate family resources

 BRIEF SCREEM FAMILY RESOURCES SURVEY (BRIEF SCREEM-RES)
– ENGLISH

Strongly Strongly
When someone in our family gets sick ... Agree Disagree
Agree Disagree

S We help each other in our family

Our culture of helpfulness, caring and concern in our

C
community is helpful to our family.

Members of our church and/or religious groups are helpful to

R
our family

E Our family’s savings are sufficient for our needs

Our knowledge and education is sufficient for us to take care of

E
our sick family member

M Medical help is readily available in our community.

Total score 12 - moderately inadequate family resources

 THE TOTAL BRIEF
SCREEM-RES SCORE
Scoring

Lubos na sumasang-ayon - 3
Sumasang-ayon - 2
Hindi sumasang-ayon - 1
Lubos na hindi sumasang-ayon - 0

Total

13 - 18 = adequate family resources

7-12 = moderately inadequate family resources
0 - 6 = severely inadequate family resources
 SCREEM ASSESSMENT
Resources Pathology

For the patient’s family, her 2 male siblings are not in good terms (Christopher
They are currently residing in Nino’s parents, they live in a separate room with
and Ronnie.) The rest of the siblings have good relationship with each other,
the patient’s mother. There are 4 families living in the house, the parents of Nino,
Christopher has good relationship with all siblings except Ronnie and Ronnie
them, and his siblings’ family.
Social has good relationship with all siblings except to Christopher.
The patient’s mother has a good relationship to everyone.He has no issue about
Nino and Jennilyn hid their relationship at first, the family of the patient didn’t
their relationship and her role as a mother to their children.
know they were living together. When they found out, the parents got mad but
The patient has a good relationship with their neighbors and Nino’s family.
accepted them anyway..

All 4 of them has their own family when their father died. So they were not
financially dependent anymore during that time. Only the youngest was the reason is the lack of companion to go to the hospital. Nino is working and her
single at that time, the remaining dependent. But they received a death benefit mother is old, no one will look for the children too.
Cultural
that they were able to use at that time. The patient is always thinking of her children but doesn’t share much about her
Her mother has a monthly pension from her father’s company. emotions to her partner right now.
The decision to admit the patient was decided by the patient’s mother.

they still believe in God. They don’t have any anger against God for what
Religious
happened to Jen.

They didn’t asked any financial help from LGU or government agencies.There
The patient’s sister and youngest male brother want to take care of the patient
are so many questions and requirements. He said he doesn’t depend from them
and supported financially (Rose Anne and John Rey) except the 2 older brothers
will just find a way later.
Economic who didn’t even call or message.
They have savings, it’s what they are using for emergency.
Nino’s family has also been supporting them financially right now when they are
Nino is currently on leave from work right now.
in the hospital.
Their children and mother take credit as of now for their daily needs.
 SCREEM ASSESSMENT

Resources Pathology

They are in public school.

Nino views education as very important. He said
Education
he will support their studies so that they can
finish.

Nino is the one staying with Jen all the

Nino who cleans and take care of everything.
time, he can’t go out at all, he cannot
Their house is distant from health center. They
process philhealth as of now because
never went to the local health center because “
Medical Jen needs attention all the time for
the center doesn’t have any use “
feeding, changing positions, changing
They have trust to the doctors because they
diaper, cleaning herself, everything.
believe in the doctor’s knowledge.
They are not members of philhealth.
SMILKSTEIN’S CYCLE OF FAMILY FUNCTION
- MANCHA & MANASSEH
SMILKSTEIN’S
CYCLE OF
FAMILY
FUNCTION -
MANCHA &
MANASSEH
 FAMILY
ILLNESS
TRAJECTORY:
STAGE I -
Onset of symptoms or illness:

The nature of illness: chronic MTB

The nature of onset:gradual onset
Characteristics of experience: pateint is sufferring from a (+) cough, (+) fever w/ (+)
dyspenea, (+) night sweat, (+) weight loss.
Impact on family: caught up on suddenness deal, vague apprehensive and anxiety,
fearful of the possible complications, therefore, the mother decided to have her
admitted. Claimed by the SO that they have a strong faith and believe in GOD. The
Family have a strong believe in the doctors and claimed that Jen’s is feeling better
compared to the day of admission.
> Patient believes that going to the hospital and being diagnosed with a disease
would help her to be cured ASAP. And to avoid being in such a worsen condition.
STAGE II
Impact phase:

When we first met the family, they were just in the impact phase of stage 2 of the
family illness trajectory. Patient was so stressed out and worried at the time not just
because she had been given a chronic illness diagnosis, but also primarily because
she has a financial reasons and she lack of companion, since her live in partner is
working and her mother is old also she is worried about her children at home since
no one will take care of them, when patient condition got worsened she almost
declined to be admitted. However, the mother, ignore this and only pay attention to
the medical aspect.

In this phase it is important to:

Educate pt on condition.
Clarify misconception.
Provide Emotional support.
STAGE III
Major Therapeutic Efforts:

The patient admitted. And started with the necessary medications.

One of the problems identified were lack of income- thus difficulty maintaining long
medications.
- At this phase we provided pt with medical options that are cost- effective and
explained to her the rationale or importance of treatment
Patient is on-going management and treatment at VSMMC.
Another identified was lack of support. With this I tried contacting the SO( live in
partner) ,and was able to discuss with them the condition of the patient as well the
importance of the treatment.
STAGE V
Recovery Phase-Early Adjustment to outcome:

Continually provide support and guidance to the family

Patient is feeling better and improving on the current hospital management.
patient is still in the hospital.
 FAMILY
WELLNESS
PLAN
 INTERVENTIONS

FAMILY MEMBER PRIMARY SECONDARY TERTIARY

DIAGNOSIS
Health Education or Treatment & lifestyle
Immunization Screening Test
Screening changes

importance of completing
the full course of therapy,
Pleural effusion L, sec. to
Pulmonary TB
G.J.A. (Index case)
PTB bacteriologically
confirmed
patients with pulmonary TB
Imaging:
Chest radiograph (CXR), PA
view
Ultrasound-Hemithorax,
Left
Piperacillin + Tazobactam
45g q8h
Microbiology:
Sputum smear and culture Azithromycin 500mg tab, 1
for acid-fast bacilli (AFB) tab OD
GeneXpert
Vit B complex tablet; 1 tab
Educate patient on the
OD
Laboratory tests:
Complete blood count (CBC) NAC 600mg tablet; 1 tab in
and on the risk of
Creatinine ½ glass of water OD
transmission to others.
Blood urea nitrogen (BUN) Continue follow ups, check
Screening for latent TB
Basic metabolic panel ( Omeprazole 40mg IV q ups and monitoring.
infection (LTBI) is
phos, mg) 24hrs
recommended for all
Bleeding Time
Hemoglobin A1C (HbA1C) Paracetemol 300mg IV for
who are candidates for
Lipid profile temp > 38C q 6hrs
treatment.
Fasting blood sugar (FBS)
Blood culture x 2 sites Give furosemide 40mg IV 1
Arterial blood gas (ABG) dose now
Serum glutamic-pyruvic
transaminase (SGPT) CBG TID q HS while on NPO
C3 and C4 complement
levels
Antinuclear antibody (ANA)
Thyroid function tests (T3,
T4)
Direct bilirubin (DB),
Indirect bilirubin (IB)
 INTERVENTIONS

FAMILY MEMBER PRIMARY SECONDARY TERTIARY

DIAGNOSIS
Health Education or Treatment & lifestyle
Immunization Screening Test
Screening changes

1. Educate the child and
family about asthma.
2. Avoid exposure to
triggers.
3. Consider daily controller
medications for
C. B.
Asthma frequent or moderate-
8/M
to-severe symptoms.
Pneumococcal Vaccine
4. Develop an asthma
action plan.
5. Have regular follow-up
visits with a healthcare
provider.
Short-acting beta-agonist
(SABA) for quick relief of
symptoms.
Inhaled corticosteroids
(ICS) for persistent
symptoms.
annual deworming Pulmonary function tests
Combination therapy with
annual Allergy testing Regular follow-up with
ICS and long-acting beta-
Influenza Vaccine healthcare provider.
agonist (LABA) for severe
symptoms.
Individualized asthma
action plan.
Avoid environmental
triggers.

periodic health exam every

1-2 times a year.
1. health risk behavior periodic height / weight
M. A. 2. medical history measurement / BMI Regular follow-up with
Essentially well annual deworming Vitamin C suplementation
6/F 3. complete physical exam healthcare provider.
4. Health guidance Nutritional counseling
5. periodic height / weight
measurement / BMI
 MEDICAL 1 Pleural effusion L, sec. to Pulmonary TB

DIAGNOSES 2 PTB bacteriologically confirmed.

3 T/C TB Spondylitis

4 CAP-MR
 Structure: Extended Family

FAMILY Family Life Cycle: Family with Young children

DIAGNOSIS
APGAR I: Highly Functional

Family Illness Trajectory

Smilkstein’s Cycle of Family Function

THANK
YOU!
Have a
great day
ahead.