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Barely a kilometer from the finish line. by: Angustia , Ayes, Chan, Co, Garcia, Macapinlac , Tumibay , Vega 23 July 2010. A Family Case Presentation. Outline. Characteristics of the New Model of Practice for Family Medicine The Family Case Presentation.
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Barely a kilometer from the finish line... by: Angustia, Ayes, Chan, Co, Garcia, Macapinlac, Tumibay, Vega 23 July 2010 A Family Case Presentation
Outline • Characteristics of the New Model of Practice for Family Medicine • The Family Case Presentation
I. Characteristics of the New Model of Practice for Family Medicine • A personal medical home for each patient • Patient-centered care • A team approach to care • Elimination of barriers to care • Advanced information systems, including integrated electronic health records (EHRs) • Redesigned, functional offices • Whole-person orientation • Care provided within a community context • Emphasis on quality and safety • Enhanced practice finances (through operating efficiencies and new revenue streams) • A commitment to provide family medicine's “basket of services”
II. The Family CP • Introduction • Clinical History of the patient • Heat stroke • Family Assessment Tools • Results of Assessments • Impact of illness to the patient and the family • Family System Theories • Conclusion and Recommendations
A. Introduction II. The Family CP
Introduction • Purpose of the presentation • Why was this case chosen? • What points will the audience focus into? • Identifying data • Chief complaint • Patient’s most obvious concern • Concern of the main caretakers
Purpose of the CP • Why was this case chosen? • A sudden situation • Timeliness • Family Medicine • PH significance
Purpose of the CP • Purposes: • Re-evaluation/formulation of the problem • Development of a comprehensive treatment plan • Guidance on issues, impasses, sensitive events • Discussion of diagnostic features, therapeutic techniques or biopshycosocial dynamics
Focus of the CP • Impact of illness to the patient and family • Coping mechanism • Family dynamics • Social resources
Identifying Data • Remus Fuentes(R.F.) • 37 y/o, Male, Married with two young children • IT expert, HP employee, Metro Manila • No known co-morbidities
Chief complaint (CC) • Loss of consciousness (LOC) • a concern of the family
B. Clinical history of the patient II. The Family CP
III. Clinical History of the Patient • Course of illness • History • PE • Diagnostics and Results • Diagnosis • Course in the ER, ICU
Course of illness • History • PE • Diagnostics and Results • Diagnosis • Course in the ER, ICU
Marathon • collapsed on 19.9km mark • taxied to Ospital ng Maynila • hyperthermic, and with seizures • given Paracetamol • intubated • family opted for transfer to Medical City
Medical City • reintubated • worked up for metabolic, neurologic and cardiac causes • Impression after evaluation: Heat stroke -- treated accordingly • doctors informed wife about the condition, its possible consequences • consent for procedures
Medical City • Patient initially stabilized • episodes of hypotension • BP of 50/30 despite being on maximum pressors • cardiac arrest • declared dead after 45 min of resuscitation
C. Heat stroke II. The Family CP
Heat Stroke • Definition • Epidemiology and Incidence • Pathophysiology • Differentials • Diagnostic work-ups • Management – pharma (include MOA if applicable) and non-pharma • Prognosis • Prevention • PH
Heatstroke • Most severe and deadly heat-related illness • Definition: Body temp 41C assoc. w/ neurologic dysfunction • 2 types • Classic • Exertional heatstroke
Epidemilogy and Incidence • Common in tropical countries Philippines • Cases increase in hot and humid weather • Increase risk for people staying outdoors and dehydrated • No sex or race predilection • Higher risk for extremes of age
Pathophysiology • Imbalance of heat gain and heat loss • Excessive heat denatures proteins in body • HSP and inflammatory cascade more damage to body
Differentials • Amphetamine or cocaine toxicity • Myocardial infarction • Stroke • Delirium tremens
Work-up • CBC • Cardiac markers • Urinalysis • Muscle function test (CK, lactate dehydrogenase) • ECG • CXR • CT scan
Treatment • Medical EMERGENCY • THERAPEUTIC HYPOTHERMIA
Treatment • Benzodiazipine • Hydration • Decrease temperature
Prevention and PH • Preventable disease • EDUCATION = most important tool
D. Family assessment tools II. The Family CP
Family Genogram I ? 37 II 8 4 III
Family Structure • Nuclear Family
Family Life Cycle Stage • Family with young children • Parent team approach • Getting used to new roles • Formation of new alliances
Other family members at-risk of the condition • Younger brother, Roy, who is also a runner • Allies in the management • Father, Rudy, who is the stronghold/rock of the family and who makes the major decisions • Mother • Brother
Family Map I ? II 37 III 8 4
Dynamics of the family • Alliances and conflicts that will compromise cooperation in patient care • Strong alliance with young wife
Illness Typology • Acute Onset • Family could not create a meaning for the illness • No time to grieve • No course – acute onset • Misdiagnosis can lead to death
Time line and phase of illness Crisis Chronic Terminal PHASES Diagnosis Death TIME LINE Initial adjustment period Chronic ‘long haul’ Mourning and Resolution of loss Pre-diagnosis w/ symptoms Pre-terminal
Stages of Grief • Father • Anger – vents his anger and frustration with the event organizers through an internet blog. Seeks justice for the untimely death of his son. • Bargaining – appearing to be strong despite the situation • Mother • Denial - mother was still wishing that the patient would regain consciousness • Wife • Anger – was hysterical at the ER. Needed the support of her sister to calm her down • Denial – could not grasp the concept the state of being “critical”
Four Areas of Assessment • Type of Illness • Flexibility and Openness of the family • Stage at which illness occurs • The role that the sick person plays
Type of Illness • Acute Severe • May uncover hidden dysfunction between wife and the in-laws • The sudden onset of the illness brings greater stress to the family • Flexibility and Openness of the family • Lifeline • Ambulance ride • Ospital ng Maynila • Transfer to TMC-ER • TMC-ICU • Code 99 after 42 hours after collapse
Coping mechanisms of family • Wife-hysterical, did not want to see husband suffering • Sister of the wife – support system for wife • Brother – in state of shock • Father – finger pointing • Mother – worried and hopeful • Stage at which illness occurs • Out-of-phase • Young, healthy male, at the prime of his life with a new family and no co-morbidities