LEC 7 Family Medicine Case

Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong

Purpose

• To serve as an example of a how a mother can disrupt the development and well-being of her child and to stress the importance of a family intervention

• Points to focus on – the progression of the patient’s disease– the reasons for inadequate treatment– the personal and social history of the patient

History

Identifying data

• PT, 12-13 years old, male• Residing in Ilugin Phase 1, a “magbabasura”

accdg to neighbors• Highest educational attainment: grade 1• Roman Catholic, social class D-E• Came in on foot, with mother and younger

sister

Chief complaint

• “masakit ang malaking daliri ng paa” (pain at the big toe)

• Concern of the main caretaker: patient is having fever episodes already, and they are scared of what may happen if the condition persists

History of Present illness• 2 days PTC – the patient hit the plantar aspect of

his right big toe on a rock, with the development of a wound– With immediate sharp pain (7/10), with pain when

pressure is applied– Still able to walk, but with a limp– Developed undocumented intermittent high grade

fever relieved by paracetamol, associated with productive cough (whitish phlegm) and colds

• Persistence prompted consult at Ilugin Community Center

Review of Systems• General: with body malaise• HEENT: no head ache, no dizziness, no blurring of

vision, no epistaxis, no dysphagia• Cardiopulmonary: no chest pain, no dyspnea, no

hemoptysis, no palpitations• GI: no abdominal pain, no change in bowel habits,

feces color brown and formed, no vomiting, no hematemesis

• Genitourinary: no dysuria, no hematuria• Neurological: no loss of consciousness• Extremities: no muscle/joint pains

Past Medical History

• No previous hospitalizations– A few episodes of diarrhea, fever and cough in the

past (uncertain time)

• No previous surgeries

Immunizations history

• BCG• 2 DPT• 2 OPV• 3 HEPA B• 1 Measles

HEADSSS

• Home– Patient lives in a depressed area with mother and

3 more siblings. – Mother is a freelance laundrywoman, step-father

is a stay-in construction worker– House is only composed of 1 room same size as

classroom 301 in ASMPH, with only 3 walls (1 side does not have a wall), no electricity, no water, no mosquito nets. House has a roof (metal sheets) which is easily blown away by wind when raining.

HEADSSS

• Home– Patient and family eats at uncle’s (neighbor’s)

house.– Patient does not have a good relationship with

mother and step-father – Mother is sometimes not home, with one account

of disappearing for over 2 months before, leaving the kids behind

HEADSSS

• Education– Highest educational attainment: grade 1 at Ilugin

Elementary school• Lives 1-2 minute walking distance from school• No tuition needed at the school• The mayor gives bags, notebooks and pens, and shoes• Uncles and aunts willing to shoulder the expenses for

uniforms– Patient expresses the longing to go to school so

that he can get a good job in the future and earn a decent living

HEADSSS

• Education– Other siblings are also not going to school while

the year-level of cousins living in the same area are at par with age

– Mother claims that she wants the children to study but all of them do not want to do so.

HEADSSS

• Activities– Hangs out with friends going around Ilugin– According to neighbors/relatives, the patient

collects garbage as a source of income (the mother asks money from him)

– Does not wear footwear, even with a foot wound– Does not read books

HEADSSS

• Drugs and other vices– According to neighbors/relatives, the patient

smokes cigarettes, but the patient denies this• Patient admits that many of his friends smoke

cigarettes

– No account of drug usage or alcohol consumption• The mother is a known alcoholic, who frequently

engages in drinking sessions with her freinds

HEADSSS

• Sex– No girlfriend, no sexual activities

• Suicide– Never thought of committing suicide

• Spirituality– Patient was baptized, but has never gone to Mass

nor has undergone Confirmation

Physical examination

Physical examination

General survey• Awake• Alert • Coherent and answers

questions completely• Not agitated and not in

apparent distress

Vital signs• Height: 130 cm (<5th

percentile)• Weight: 20 kg (<5th

percentile)• BMI: 11.8 (< 5th percentile)• Temp: 36.6C• HR: 80 beats per minute• RR:32 beats per minute• Pain scale: 7/10

Physical examination

HEENT• With lice and nits• Anicteric sclerae, pink

palpebral conjunctiva• No TPC, no CLAD

Chest, lungs, heart• Symmetric chest expansion,

resonant lung fields, with occasional rhonchi at bilateral lower lung fields

• PMI at 5th ICS LMCL, normal rate, regular rhythm, no murmurs

Physical examination

Abdomen • Flat, with normoactive

bowel sounds, tympanitic all 4 quadrants, nontender and soft

Extremities • The plantar aspect of the

1st digit of the right foot was erythematous and tender, with apparent pus underneath

• Pulses full and equal• Patient was limping

Initial clinical assessment

Initial clinical assessment

• Abscess of the plantar aspect of the first digit of the right foot

• Pneumonitis, resolving• Undernutrition

Initial family medicine assessment

Initial family medicine assessment

• Family structure: blended and random family• Life cycle: family with adolescents• Family apgar:

Plan

Initial plan

• Paracetamol 250mg/5ml, 6 ml every 4 hours for fever (10mkdose)

• Co-amoxiclav 250mg/5ml, 6ml every 8 hours for 7 days– Was given only 2 5ml bottles and was told to purchase the

rest• Active and passive tetanus vaccination• Drainage of abscess if no improvement after 3 days• Advised better diet• Advised to seek assistance for education of patient• Advised to buy or borrow a thermometer

Course of illness

Day 2 of illness

• Home visit– The night before, the patient developed an

undocumented high-grade fever. He then was brought to a local faith healer who punctured the abscess with a non-alcoholized, flame-exposed needle. Pus was drained. the fever lysed

– During the visit, the patient avoided ASMPH clerk– Patient still was not wearing any footwear

Day 2 of illness

• Home visit– Patient was not given the required dose of

medications needed per day (2.5ml co-amox BID) and was told that the rest was to be purchased after the visit. Financial constraint.

– Still with no tetanus vaccinations– Patient was still limping, but to a lesser extent– Patient was afebrile– Lesion was less tender

Day 2 of illness

• Home visit– Noted a nontender, movable, reducible mass a

the left inguinal area that disappeared upon lying down and appeared after coughing while standing up (possible indirect inguinal hernia).• Further probing – was present since birth

– 1-on-1 consult (HEADSSS)

Day 2 of illness

• While talking with CHW’s– Mother is a drunkard– Patient collects garbage for cash, mom gets the cash– All siblings of the patient also are not going to school– Mom disappeared for 2 months, leaving the kids

behind– Mom and dad are separated, mom has live-in partner

• Patient did not go to the OPD – Changed the medications to cefalexin and gave the

full amount, Ate Carla (CHW) was in charge

Day 6 of illness

• Home visit– Mother was not there– Patient was still walking without footwear – Marked improvement of the toe, patient was

walking straight, but still with pain 2/10.– Invited the patient, aunt, and neighbor for family

conference in 2 days, with invitation also extended to mom.

Family conference

People who attended

• Dr. Limuel• 3 ASMPH clercks• 2 TMC pedia residents• Patient• Aunt• Neighbor• 2 cousins• Mother did not attend

Topics discussed

• Reason for conference: the patient and his well-being– Problems with the treatment– School– Family and home

Problems with treatment

• How come the patient under-dosed?– Financial– Human factor (mother and apparent

incompetence)– Patient’s feelings and fears about doctors– Apparent uncooperativeness with regards to

drinking the medications• Seeking outside help for drainage of pus– Feelings of patient about going to the hospital

Problems with treatment

• Tetanus vaccinations– Money issues– Toxoid vaccinations for free at health center– Passive immunity as a problem financially

School

• Why isn’t the patient in school?– The givens:• The school is so near where they live• No tuition• School supplies provided by the mayor• Uniforms to be shouldered by aunts and uncles

– Therefore what is the problem???• No birth certificate• Mother does not seem to care• The kid needs to work to bring in money

Family and home

• Step-father is never home, although maintains fair relationships with kids– Just got out of prison

• Mother does not seem to care for the kids• Mother brings little food to the table• Everyone continuously tells mother about the

children but the mother doesn’t seem to care

Family and home

• History of mom: eldest, looked after her siblings since she was young, and practically raised them– Insight of aunt: maybe this time she just was

burned out and wanted to live the life she missed