I.

INTRODUCTION
The institution of family is something that can never be emphasized
enough. In the dictionary the word family means; a basic social unit consisting of
parents and their children, considered as a group, whether dwelling together or not.
However, the structure of families has changed right along with the times. The term
family can be defined as "a group of individuals who are bound by strong emotional
ties, a sense of belonging, and a passion for being involved in one another's lives
(Wright and Healey, 2000).
The word family comes from the Latin word "familia", which means
household. In the Philippine context, it cannot be denied that Filipinos have strong
close-knit family ties. A typical Filipino household is composed of elders, parents,
and children. According to Haviland (2002), families are affected by, and in turn
affect, the values and structure of the society, in which they are embedded. This
statement says so much about what families are and why they differ so much from
one culture to the next. They fill the needs of each particular group.
As future doctors, we must understand the index patient, not only as an
individual but as part of a family. We must first gain an understanding of family
background. Working with family from a systems perspective, one is able to gain an
understanding to the ways in which family members interact, what the family norms
and expectations are, how effectively members communicate, who makes
decisions, and how the family deals with needs and expectations (Edleman &
Mandle, 2002).
In the concept of systems theory, a family can exist within a community
(suprasystem) and at the same time have smaller relationships within that family
(subsystems). By composing a genogram, or family tree, one can see information on
family relationships, health patterns, occupations, and religion. By composing an
Ecomap, one can see information on how a family and its members interact with
larger systems or smaller subsystems.
In line with this, the family health care program and assistance of the
Department of Community and Family Medicine would be essential to address the
needs of our Service family. They can be educated regarding their illness, the
availability of health care resources that may be of benefit to them, the accessibility
to multidisciplinary approach that will help address the physical, emotional, spiritual
and social concerns that arise with advanced illness and the services that can help
them alleviate our index patients sufferings and improve not only his but also the
whole familys quality of life.

II. OBJECTIVES

1. To be able to describe the Alataya Family as to:

a. Family structure
b. Psychosocial function
c. Economic status
d. Environmental profile
2. To evaluate the health status of the index patient and family members;
3. To provide treatment and management to the present health condition of the
family especially the index patient;
4. To assist and educate the family on how to address the needs of the index
patient for his illness such as:
a. Diagnostic work ups
b. Medications
c. Lifestyle modification
5. To educate the family on the nature of illness, and in health promotion and
disease prevention activities;
6. To identify other existing biopsychosocial concerns within the family.

CLINICAL HISTORY
Informant: Patient
Reliability: 75%
General Data:
Alutrya, Efren Guis, 56 years old, male, married, unemployed, Roman
Catholic, born on October 31, 1957 in Masbate, presently residing at 149 St. Paul,
Area 4C, Republic Ave., Brgy. Holy Spirit, Quezon City, first seen during a home visit
on February 12, 2014.
Chief Complaint:
Perianal mass
History of Present Illness:
The history of present illness started 1 year and 5 months prior to home visit,
when the patient noticed a 1x1 non-tender, reducible mass on the perianal area.
Associated signs and symptoms include blood-streaked soft stools which occurred
approximately 3-5 episodes per day, pain upon defecation, and decrease in
appetite. There were no associated fever, vomiting, abdominal pain, constipation
and weight loss. No consult was done. No medication taken.
One year prior to home visit, the patient noted that the perianal mass
increased its size to approximately 2x2 cm. He also noted that the mass became
tender and non-reducible. This was associated with blood- streaked soft stools of
approximatey 3-9 episodes per day, which was scanty to moderate in amount, pain
upon defecation and weight loss of about 10kg (from 72kg to 62kg). There were no
associated fever, vomiting, abdominal pain, constipation, easy fatigability and
dizziness. He sought consult at East Avenue Medical Center where a complete blood
count was done, which later revealed anemia (haemoglobin=97, hematocrit=0.33).
Chest X-ray, electrocardiogram, fasting blood glucose, serum creatinine, sodium and
potassium were also done which all revealed normal results. Colonoscopy with cold
biopsy extirpation and hot snare polypectomy was done, which later revealed
mulitiple colonic polyps measuring <0.5 - >2cms and a nodular friable ulcerated
anal mass. Specimen were sent for histopathology and revealed Adenocarcinoma,
Well Differentiated. He was given Ferrous sulfate 1 tablet once a day which he took
for 1 month. The patient was advised for further work-up but he was lost to follow
up due to financial constraints.
Six months prior to home visit, still with the above signs and symptoms, he
noted further increase in the size of the mass, measuring about 3x3 cm with
associated anal pain, which he described as moderate, continuous distending pain,
non-radiating with a VAS of 6/10. No precipitating or aggravating factors noted. He
self-medicated with Mefenamic Acid 500mg/tab 1 tablet, 3-4 times per day which
afforded temporary relief. No consultation or treatment was done.

One month prior to home visit, still with the above signs and symptoms, he
was noted to be pale, with associated easy fatigability, dizziness and difficulty in
defecation. He continued taking Mefenamic Acid 500mg/tab 1 tablet 3-4 times per
day, which afforded no relief at all. The persistence of the above signs and
symptoms prompted the patient to seek consult at the Barangay Holy Spirit Satellite
Health Center where he was subsequently seen.
Past Medical History
The patient had the usual childhood illness such as mumps, measles, chicken
pox. He is non-diabetic, non-hypertensive and non-asthmatic. No previous
hospitalizations, major operations, blood transfusion, accident or trauma. He denies
any history of pulmonary tuberculosis, heart diseases, liver diseases, kidney
diseases or sexually transmitted diseases.
Family History
Father a known hypertensive, deceased at 81 years old due to
complications of PTB
Mother deceased at 57 years old due to unknown causes
The patient is 3rd among 11 siblings, 8 of whom are deceased of the following
causes:
1st sibling - Food poisoning at age 45
2nd sibling - PTB at age 56
4th sibling - Colon cancer at age 50
5th sibling - Measles at age 31
6th - Complications of intrauterine fetal uterine demise at age 35
7th - unknown cause at age 5
8th sibling - brain tumor at age 40
9th sibling - unknown cause at age 1
The patients youngest sister (10th sibling) is apparently well while his
youngest brother (11th sibling) is diagnosed with colonic polyps. He denies other
heredofamilial diseases such as cardiovascular accident, lung diseases, liver
diseases and kidney disease.
Personal and Social History
The patient is an elementary undergraduate (Grade 5). He worked as a
subcontractor (foreman) for almost 20 years but has stopped working since 2013.
He is married to his first wife in 1978, whom he had 2 sons and 1 daughter
but was separated in 1986. He later remarried and had a 2 nd wife for about 16
years, whom he had 2 sons and 4 daughters but they eventually got separated.
He is currently living with his 3 rd partner, Ester Remitar, 45 years old, for 6
years now with their 2 sons in a bungalow type house with 1 bedroom, 1 bathroom
and a kitchen with adequate ventilation, electricity, clean water supply and regular
garbage collection twice a week.
The patient used to be an alcoholic drinker, consuming 12 bottles of gin/day
for 3-4x/week. He stopped drinking alcoholic beverages in 1985. He is also a 15pack year smoker and has stopped smoking since 1991. He has no food
preferences. He has no known allergies to food or medication.

Review of Systems:
Constitutional: (+) weakness, (-) fever, (-) chills, (+) loss of appetite
Skin: (+) pallor, (-) itchiness, (-) excessive dryness or sweating, (-) jaundice
Head: (-) headache, (-) vertigo
Eyes: (-) pain, (-) blurring of vision, (-) lacrimation, (-)photophobia, (-) use of
eyeglasses
Ears: (-) ear pain, (-) deafness, (-) tinnitus, (-) ear discharge
Nose and Sinuses: (-) change in smell, (-) nose bleeding, (-) nasal obstruction, (-)
nasal discharge, (-) pain around paranasal sinuses
Mouth and Throat: (-) toothache, (-) gum bleeding, (-) disturbances in taste, (-) sore
throat, (-) hoarseness
Neck: (-) tenderness, (-) limitation of movement, (-) mass
Breast: (-) pain, (-) lumps, (-) nipple disturbances
Respiratory System: (+) dyspnea, (-) chest pain, (-) cough, (-) sputum production, (-)
hemoptysis
Cardiovascular System: (-) substernal pain, (-) palpitation, (-) dyspnea, (-)
orthopnea, (-) paroxysmal nocturnal dyspnea, (-) edema, (-) cyanosis, (-) syncope
Gastrointestinal System: (-) abdominal pain, (-) nausea, (-) vomiting, (-) dysphagia,
(-) melena, (-) regurgitation
Genitourinary System: (-) dysuria, (-) urinary frequency, (-) urgency, (-) hesitancy,
(-) polyuria, (-)hematuria, (-) incontinence, (-) urethral discharge, (-) genital pruritus
Extremities: (-) edema, (-) swelling of joints, (-) stiffness, (-) numbness, (-) limitation
of movement
Nervous System: (-) headache, (-) vertigo, (-) syncope, (-) loss of consciousness, (-)
weakness, (-) paralysis, (-) paresthesia, (-) speech problem, (-) loss of memory, (-)
confusion
Hematopoietic System: (-) bleeding tendency, (-) easy bruising, (-) history of blood
transfusion reaction
Endocrine System: (-) intolerance to heat or cold, (-) excessive weight gain or loss,
(-) polyuria, (-) polydypsia

Physical Examination:
General Survey: Patient is conscious, coherent, afebrile, oriented to time, place and
person, looks his age, not in cardiorespiratory distress, without gross deformities,
with the following vital signs:
BP: 100/70mmHg
CR: 82bpm
RR: 20 cpm
Temp: 36.7 C
Height:
158cm
Weight: 58.1kg
BMI: 23.3 (Normal)
Skin: Brown complexion, normal degree of moisture, elasticity, mobility and
thickness, black short hair of normal quantity and even distribution, nail beds are
pink, nail plates are smooth, no lesions, nail folds are normal
Head: Hair is thin, black with grayish streaks, normocephalic, no masses temporal
arteries are visible with strong equal pulses.

Eyes: Eyebrows are b;ack, thin evenly distributed, no erythema, no ptosis and no
lesions noted; palpebral fissures are narrow and symmetrical, eyeballs are normally
set, eyelashes are thin with outward direction of growth, no matting, pale palpebral
conjunctivae,dirty looking sclera, transparent cornea, lens are clear, iris are black
with regular contours, pupils are 2-3mm equally reactive to light and
accommodation. No exophthalmos nor enophthalmos. No nystagmus.
Ears: Auricles are symmetrical and non-tender, auditory canal are patent, tympanic
membranes are intact with visible cone of light
Nose: Nose is symmetrical, patent vestibules, mucosa is pink, septum midline and
intact, turbinates are not congested, no nasal discharge, no tenderness over the
frontal and maxillary sinuses.
Mouth and Oral Cavity: Lips are dry, buccal mucosa and gums are pink and moist,
smooth, no signs of swelling. Tongue is at midline. Hard and soft palate are pinkish,
no lesions, uvula is at midline, tonsils are not enlarged, pharyngeal wall is pinkish
with no exudates.
Neck: Neck is normal in size, supple, symmetrical, no neck vein engorgement, no
mass, normal muscle development and tone, trachea in midline, soft, no palpable
lymph nodes, thyroid gland not palpable. No carotid bruit noted.
Lung/Chest: Skin is brown, no lesion, no dilated superficial blood vessels, bony
thorax is elliptical, symmetrical without gross deformities, no tenderness, lung
expansion is symmetrical, no retraction, with clear breath sounds.
Heart: Adynamic precordium, normal rate regular rhythm, no thrills, no murmur nor
heaves. The apex beat is at the 5th intercostals space left midclavicular line.
Abdomen: Soft, flat, nontender, with normoactive bowel sounds
Rectal Examination: (+) 9cm x 6cm erythematous, tender, firm nodular mass
surrounding the perianal area, (+) greenish brown material from the anus.
Extremities: No gross deformities. Full and equal pulses, no edema, no cyanosis
Neurologic Examination:
Cerebrum: Patient is conscious, coherent, oriented to time place and person
Cerebellum: No nystagmus
Cranial Nerves:
CN I: can smell
CN II: 2-3mm pupils equally reactive to light and accomadation
CN III, IV, VI: equal and complete opening of both eyes, intact extraocular
muscles
CN V: can feel pain and light touch on both sides of the face, (+)corneal
reflex, can clench teeth, (-) jaw jerk
CN VII: can frown, raise eyebrows, close eyes tightly, no facial asymmetry
CN VII: can hear on both ears
CN IX, X: uvula at midline, equal elevation of palate on phonation
CN XII: tongue midline, mobile, no atrophy nor fasciculation

Motor
5/5
5/5

5/5
5/5

Sensory
100%
100%

100%
100%

DTR
++
++

++
++

Pathologic Reflexes: (-) babinski, (-) ankle clonus

Signs of meningeal irritation: (-) nuchal rigidity, (-) Brudzinski, (-) Kernigs
Assessment: Colorectal Adenocarcinoma
Plan:
Diagnostics:
CBC, Urinalysis, Fecalysis
Drugs:
Ferrous sulfate 1 tablet BID
Tramadol 50mg/tablet, 1 tablet every 6 hours for pain
Diet: High fiber diet
Increase oral fluid intake
Avoid dark-colored food
Disposition:
Refer to surgery for further evaluation
Refer to palliative service for pain control and palliative care
Refer to social service for facilitation of diagnostic workups
To come back at the local health center or Out Patient Department of FEUNRMF Medical Center anytime or if with problem
Instructions given
Concerns addressed
Advised
Wellness Plan:
Encourage patient establish and maintain positive relationships with family
and friends
Encourage patient to acknowledge and share feelings of anger, fear, sadness
or stress; hope, love, joy and happiness in a productive manner
Advise patient to adopt healthful habits (routine check ups, a balanced diet,
exercise, etc.) while avoiding destructive habits (tobacco, drugs, alcohol, etc.