LAUREO FAMILY

A Family Case Presentation

Adhikari, Swastika
Adriano, Angelica Rose
Alfelor, Remelou
Apolinar, Chadwaren
Bernal, Margaret
Bhujel, Amid
Boller, Jino
Buansay, Yousri
Caluag, Eymar
Camaganacan, Ma Shiela
 General Objective:
O To be able to present a family case using the
different tools for evaluation
 Specific Objectives
O To present the index patients medical history,
physical examination, diagnosis and
management
O To evaluate the Laureo family using the
different tools of assessment
O To develop a wellness plan for Laureo
Family
O R.C.L.
O 59 yr old male
O Single
O Farmer
O Living at Balete 2, Silang Cavite
O Roman Catholic
O Chief Complaint: Easy fatigability
HISTORY OF PRESENT ILLNESS
(+) dark red (bloody) stool, intermittent
3 months PTA
(-) abdominal pain, (-) vomiting
(-) easy fatigability
(-) medication taken, (-) consult done

2 months PTA Dark red (bloody) stool spontaneously

resolved
(-) abdominal pain, (-) vomiting
(-) easy fatigability
(-) medication taken, (-) consult done
HISTORY OF PRESENT ILLNESS
O 1 month PTA (+) generalized body weakness
(+) numbness of extremities
(+) chest pain, stabbing in character,
radiates at the back
(-) dark red (bloody) stool
(-) abdominal pain, (-) vomiting
(-) easy fatigability
(-) medication taken, (-) consult done

CONSULT Persistence of symptoms

 Review of Systems
O No night sweats
O No nasal discharge, no cough, no fever
O No weight changes
O No Headache, blurring of vision, tinnitus, hearing problems, or
dizziness
O No DOB, orthopnea or PND
O No nape pain
O No Abdominal pain, nausea/vomiting, BM changes, or urinary
symptoms
O No Arthralgias
 Past Medical History
O Hospitalization lacerated wound right forearm
O (-) Hypertension, DM, allergies, asthma
 Family History
O CVD paternal (deceased), 2 siblings (deceased)
O Liver Disease brother (deceased)
O Hypertension maternal (deceased)

O (-) cancer
O (-) hematologic disease
 Personal/ Social History
O Non-smoker
O Heavy alcoholic drinker
O 3x a week since 12 y/o, hard drinks

O Denies illicit drug use

O Works as a farmer
 Physical Examination
O General Survey: Conscious, coherent, ambulatory
O Vital Signs:
O BP 110/80 HR 75 beats /min RR 19 breath/min T
36.8
O HEENT:
O Pink palpebral conjunctivae, anicteric sclerae, no
nasoaural discharge, moist buccal mucosa, non
hyperemic posterior pharyngeal wall, tonsils not
enlarged
 Physical Examination
O Supple neck, (-) CLAD, (-) NVE
O SCE, no retractions, clear breath sounds
O Adynamic precordium, NRRR, no murmurs
O Flabby, NABS, soft, nontender
O DRE: intact sphincter tone, no blood in examining
finger, no mass palpated, non-tender prostate
O Ext: no edema, no cyanosis, pulses full and equal
 Physical Examination
O Neurological Exam:
O GCS 15
O conscious, oriented to time, place & person
with intact recent and remote memory
O Cranial Nerves: intact
O Motor: 5/5 on both upper and lower
extremities
O Sensory: 100% on both upper & lower
extremities
 Assessment
O Anemia secondary to UGIB probably
secondary to
1. BPUD
2. Bleeding Esophageal Varices secondary
to chronic liver disease probably
secondary to alcoholic liver disease
 Plan
O For blood transfusion (4 units pRBC)
O Diet: LSLF
O IV PNSS 1Lx 16 hours
O Diagnostics:
O 12 lead ECG
O CXR
O CBC with PC
O UA
 Plan
O Diagnostics:
O SGPT, blood uric acid, PT, PTT
O for WAB
O Na, K, Crea, BUN
O CBG, Blood Typing
O Trop I
O Medication: Omeprazole 40 mg OD IV
 Anemia
O Anemia secondary to upper gastrointestinal
bleeding often roots from breaks in the
mucosal surface > 5mm, also known as
ulcer
O Most common risk factors would be
chronic use of NSAIDs and H. pylori
infection.
O Alcohol use is also a noted risk factor for
developing esophageal varices that can
lead to anemia.
 Family Profile
NAME AGE EDUCL OCCUPATION RELIGION
ATTAINMENT
Ruben 59 Elementary Farmer Roman Catholic
Luciano Unknown * Elementary Farmer Jevohas Witness
Teresa Unknown * Elementary Farmer Jevohas Witness
Filipe 70* Elementary Farmer Roman Catholic
Virencia Unknown Elementary Housewife Roman Catholic
Wenislao 69* Elementary Farmer Roman Catholic
Rudolfo 68 Elementary Unemployed Roman Catholic
Preseo Unknown* Elementary Farmer Roman Catholic
Perla 62 Elementary Housewife Jevohas Witness

Ilna 54 Elementary Housewife Roman Catholic

* deceased
 Family Map

Luciano RUBEN Teresa

Filipe
Perla
Vivencia Ilna

Presco Wensiloa Rudulfo

FAMILY CIRCLE
PERLA

ILNA

RUBEN
RODOLFO
Family Structure and Function
O Type of family: Nuclear
O Set-up: Democratic
O Stage of family life cycle: Family in later
years
O Role and function:
O Breadwinner: Luciano
O Caregiver: Teresa
O Decision makers: Both Luciano and Teresa
 Environmental Profile
O Patient resides in Balete 2, Silang Cavite which is own by his
boss
O Area is 3,000 sqm
O House is a bungalow with a floor area of about 150 sq meters
made of wood & concrete w/ 2 bedrooms and 2 bathroom
O Water supply is from Deep well
O Electricity from Meralco
 Environmental Profile
O Garbage is collected regularly
O 4 dogs, 1 goat, 40 roosters and 2 wild pigs
O Fairly lighted with adequate ventilation
O House is fairly kempt with gas stove situated
outside of the house
Floor Plan
Floor Plan
House Entrance Roosters Area
Lanai

Garage Area
 Sala

Front Entrance

Patients Room
Kitchen
 Dirty Kitchen1
Bathroom 1

Dirty Kitchen 2
 Roosters Training Area

2 pet wild pigs

Water Pump
 Economic Profile
O Total income: approx. P 3,000/month
O Total expenses: P 3,000
O Following were provided by patients boss
O Food:
O Electricity:
O Water:
O Medicine:
O Miscellaneous P 500
O Leisure P 500
O Support for relatives P 2,000
APGAR
 Palagi (2) Paminsanminsan (1) Halos hindi (0)

Akoy nasisiyahan dahil nakakaasa

ako ng tulong sa aking pamilya sa /
oras ng problema
Akoy nasisiyahan sa paraang
pakikipagtalakayan sa akin ng aking /
pamilya tungkol sa aking problema
Akoy nasisiyahan at ang aking
pamilya ay tinatanggap at
sinusuportahan ang aking mga nais /
na gawin patungo sa mga bagong
landas para sa aking ikauunlad
Akoy nasisiyahan sa paraang
ipinadadama ng aking pamilya ang
kanilang pagmamahal at /
nauunawaan ang aking damdamin
katulad ng galit, lungkot, at pag-ibig
Akoy nasisiyahan na ang aking
pamilya at ako ay nagkakaroon ng
panahon sa isat isa
/
 APGAR I
Interpretation:

7/10
Moderately dysfunctional family
 SCREEM
STRENGTH
SOCIAL Healthy relationship with his family.
Patient text his sisters and
brothers everyday. Sometimes
they visit him in his place.
CULTURAL Close ties with family and intact
family values.
RELIGIOUS Patient goes to mass regularly. And
prays to God everyday/
WEAKNESS
Siblings live far away from
patients place.
Patient believes in albularyo and
faith healers.
Most of Rubens sibling are
Roman Catholic and only Perla
chose to stay as a Jehovah's
Witness. Problems may arise
with the different view point in
religion.
 STRENGTH WEAKNESS
EDUCATIONAL All family members can read and Most of family members were
write. high school undergraduate.

ECONOMIC Patient was able to make ends meet
through his salary in the farm and
able to give to his sibling whenever
they ask him.
MEDICAL Patients boss helps in the medical
expenses.
No extra money for medical
diagnostics and other
miscellaneous expenses
No money saved for emergency
purposes
Patient was lost to follow-up after
his hospitaliation.
Family Wellness Program
 Ruben Laureo (index patient)
TYPE OF CARE PROBLEM RECOMMENDATIONS
MEDICAL
 Ruben Laureo (index patient)
PSYCHOSOCIAL

WELLNESS

OTHERS
 Rudolfo Laureo
TYPE OF CARE PROBLEM RECOMMENDATIONS
MEDICAL
 Rudolfo Laureo
PSYCHOSOCIAL

WELLNESS

OTHERS
 Perla Laureo
TYPE OF CARE PROBLEM RECOMMENDATIONS
MEDICAL

PSYCHOSOCIAL
 Perla Laureo

WELLNESS

OTHERS
 Ilna Laureo
TYPE OF CARE PROBLEM RECOMMENDATIONS

MEDICAL
PSYCHOSOCIAL

WELLNESS

OTHERS
Thank You