Professional Documents
Culture Documents
Family Case
Janel Enriquez
Weshley Manarin
Charles Lao
May 20, 2016
The house
Semi concrete house
1 bedroom
1 comfort room
Living room
2 electric fan
1 TV
Dining room
4 windows
1 gas stove
open drainange
Good ventilation
Toilet: flushed toilet
Garbage disposal: daily
collection
Water source: laguna
water & distilled water
FAMILY STRUCTURE
Structure:
Unilaterally Extended family
Family socio-economic class patterns:
Middle-class
Family set-up:
Democratic
PSYCHOSOCIAL DATA
Leader
Juanito
Breadwinner
John
Primary
Caregiver
Annaliza
GENERAL DATA
M.A.
/ female/ Married
Roman Catholic
Filipino
October 19, November, 4,
1936
Pampanga
Bian, Laguna
CHIEF COMPLAINT
Informant : Patient
%Reliability: 90%
FAMILY HISTORY
(+) Hypertension Paternal
(+) CVA Both
(+) PTB Maternal
FAMILY
ASSESSMENT
FAMILY GENOGRAM
Agido, 72 y/o
ALCAZAR FAMILY
Bian, Laguna
May 19, 2016
Secundina, 82 y/o
Cuenco,
Capili
Adoracion 80
Juanito 78
Dong, 65Augusto, 60
Mercedita , 79
June 3 , 1962
Jonathan, 53
John, 48
Annaliza, 48 Jose, 45
LEGEND:
Informant: Mercedita
Informant: 90%
-DM
-Cancer/Colon
- Hypertension
Nathaniel, 23
Patrick, 21
Kabella, 19
FAMILY APGAR
(Daughter-in-law)
APGAR
ADAPTATION
QUESTIONS
Almost
Some of
Hardly
always
the time
ever (0)
(2)
(1)
problema.
Akoy nasisiyahan at ang aking pamilya ay
FAMILY APGAR
(Husband)
APGAR
ADAPTATION
QUESTIONS
Almost
Some of
Hardly
always (2)
the time
ever
(1)
(0)
problema
Akoy nasisiyahan sa pakikipagtalakayan
problema.
Akoy nasisiyahan at ang aking pamilya
lungkot at pag-ibig
Akoy nasisiyahan na ang aking pamilya
at ako ay nagkakaroon ng panahon sa
isat isa.
FAMILY APGAR
(Patient)
APGAR
ADAPTATION
QUESTIONS
Almost
Some of
Hardly
always (2)
the time
ever
(1)
(0)
problema
Akoy nasisiyahan sa pakikipagtalakayan
problema.
Akoy nasisiyahan at ang aking pamilya
lungkot at pag-ibig
Akoy nasisiyahan na ang aking pamilya
at ako ay nagkakaroon ng panahon sa
isat isa.
FAMILY SCREEM
SCREEM
SOCIAL
RESOURCES
CULTURAL
RELIGION
ECONOMIC
EDUCATIONAL
MEDICAL
PATHOLOGY
Trajectory of Illness
Stage IV: Early adjustment to outcome
Family in Functional
Equilibrium
ADAPTATION
Caregivers
knowledgeable of
the diagnosis and
caring for the
patient
Smilksteins
Cycle of
Family
Function
RESOURCES
REVIEW OF SYSTEMS
NEUROLOGIC
No headache, no seizures
SKIN
No jaundice; senile
HEENT
CARDIOVASCULAR
No orthopnea, no palpitation
GASTROINTESTINAL
No constipation, no diarrhea
URINARY
No dysuria, no hematuria
GENITALS
No discharge, no redness
EXTREMITIES
No edema, no limitation of
movement
HEMATOLOGIC
No bleeding tendencies
PHYSICAL EXAMINATION
GENERAL SURVEY
Awake, conscious, coherent, not in cardiovascular distress
VITAL SIGNS
BP: 140 / 70 mmHg
PR: 81 bpm
RR: 20 cpm
Temp: 36.70C
O2 Sat: 99%
SKIN
warm to touch, senile skin
turgor,
no active dermatoses
HEENT
Anicteric sclerae,
pink palpebral conjunctiva,
no nasoaural discharge, no
tonsillopharyngeal congestion,
no cervicolymphadenopathy,
(-) dry lips
CHEST / LUNGS
Symmetrical chest expansion,
clear breath sounds
(-) retractions
HEART
Adynamic precordium,
normal rate, regular rhythm,
no murmur
ABDOMEN
Flat, normoactive bowel
sounds, soft, non-tender,
(-) hepatomegaly
EXTREMITIES
Grossly normal extremities,
full and equal pulses, (-)
edema,
(-) cyanosis
NEUROLOGIC EXAMINATION
CEREBRUM
MOTOR
CEREBELLUM No nystagmus
CN I
Can smell
CN II
CN III,IV, VI
CN V
CN VII
No facial asymmetry
CN VIII
Able to hear
CN IX, X
CN XI
CN XII
Tongue at midline
5/5
5/5
5/5
5/5
100
SENSORY %
100
%
DTR
100%
100%
++
++
++
++
FAMILY WELLNESS
PLAN
Mercedita, 79/F
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
Breast exam: self breast a& MD exam regularly
ANNUAL: papsmear ,DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Mercedita, 79/F
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: DT
Developmental monitoring
Juanito, 78/M
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
ANNUAL: DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Juanito, 79/F
Screening
Health behavior: smoking, alcohol, caffeine,
occupational hazard, accident
Immunization: DT
Developmental monitoring
John, 43/M
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
Family planning
ANNUAL: DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
John 43/M
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal
Developmental monitoring
Annaliza, 42/F
Screening
BP: annual
Annual cholesterol, fbs, bun, creatinine, uric acid
Visual acuity: annual & eye pressure screen for
cataract at 50 onwards
Hearing: depend on work exposure
Breast exam: self breast a& MD exam regularly
ANNUAL: papsmear ,DRE, FOBT, FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Family planning
Annaliza, 42/F
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal
Developmental monitoring
Nathaniel, 23/F
Screening
BP: annual
Annual cholesterol, fbs
Visual acuity: annual
Hearing: depend on work exposure
ANNUAL: FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal
Developmental monitoring
Patrick, 21/M
Screening
BP: annual
Annual cholesterol, fbs
Visual acuity: annual
Hearing: depend on work exposure
ANNUAL: FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal
Developmental monitoring
Kabella, 19/F
Screening
BP: annual
Annual cholesterol, fbs
Visual acuity: annual
Hearing: depend on work exposure
ANNUAL: FA, UA, CXR, PE
Hygiene: dental, bathing, nails, handwash
Screening
Health behavior: smoking, alcohol, sex life,
caffeine, occupational hazard, accident
Immunization: pneumococcal
Developmental monitoring
Final Diagnosis
Type of family: Unilaterally extended
Family APGAR: Highly functional family
Family SCREEM:
Family has adequate resources to cope with
crisis
Stage of Family Life Cycle: Family in later years
Trajectory of Illness:
Stage IV Early adjustment to outcome
Smilksteins cycle of family function:
Family in equilibrium
Final Diagnosis
Biomedical Diagnosis: