OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

FAMILY CASE ANALYSIS
Patients Name:

LAMBERTO AUSTRIA

Age/Sex:

60/M

Address:
Initial
Impression:

633 Basco St., Intramuros Manila

Mixed Wound Infection, distal
area, left leg
Diabetes mellitus Type 2,
uncontrolled
Dr. Janice Paras

Resident-inCharge:
Medical Internsin-Charge:

Date of
Visit:
Time of
Visit:

May 15,
2014
10:00 AM

Ezekiel T. Arteta and Charlene R.

Bularan
CLINICAL ABSTRACT

This is a case of a 60 year-old male, married, Filipino, Roman Catholic member,

vendor, from Intramuros, Manila. Patient had a chief complaint of plaques.
History of Present Illness:
Patient is as known case of Diabetes Mellitus Type 2 for ~2 years, maintained
on Metformin 500mg OD, pre-breakfast, with poor compliance. Last consultation to
a Health Center was 6 months prior to visit, allegedly with an FBS of 165 mg/dl
(from 185 mg/dl). Patient is in good vital capacity and was apparently well, until
Approximately 1 month prior to visit, patient experienced gradual onset of
pruritus on his left foot. No associated numbness, tingling sensation or changes in
the skin color of the extremities. Patient only scratch the area, with temporary relief
of the symptom. No consult was done, no medications taken.
In the interim, because of the constant scratching of his left foot, the affected
area developed reddish ulceration, and eventually into plaques and crusting. Still,
no consult done nor medications taken.
Persistence of the symptoms prompted consult.
Past Medical History:
a. Adult Illnesses:
Medical
No hypertension, Coronary Artery Disease, CVD, PTB,
:
bronchial asthma, pneumonia
No previous hospitalization, trauma or surgery
Surgical
No previous trauma or surgery.
:
Psychiatric
No history of experiencing psychiatric diseases.
:
b. Immunizations: No History of Adult Immunizations

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
c. Allergies

: No allergy to food or drugs

Family History:

The patient had 11 children, most of which are now married, and are starting
their families in Pangasinan and Ilocos. Raymark is the only person that helps the
index patient and his wife to their everyday needs. He works as a pedicab driver.
Patient allegedly had a healthy family. No history of hypertension, diabetes,
obesity, CAD, CVD, asthma, pneumonia, or any allergy to his children and
descendants.
Personal and Social History:
Patient is a known smoker, with 20 packyears. Also, he occasionally drinks
alcoholic beverages. He denies illegal drug use. Patient eats three times a day, with
preference to vegetable, coffee, and rice.
Patient works as a vendor of street foods (at Round Table). Their source of
drinking water is from NAWASA. The garbage is collected daily, and they dont have
pets inside their house.
FICA Spiritual History:
FAITH:
He said that if he has problems, he prays to God and goes to the priest for
spiritual guidance. However, he rarely hears mass.

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
IMPORTANCE AND INFLUENCE:
His faith is important to him because it is through his faith that he forgets his
problems.
COMMUNITY:
He is not a member of any Church/civic organization.
AWARENESS AND ADDRESSING:
He is aware of his condition and hopes that his healthcare provider will advise
him of what can be done for his condition.
Review of Systems:
a.

Constitutional: Weight loss was noted after the onset of his diabetes,
estimated to have lost 25% of the total body weight. No fever, chills and
fatigue.

b.

Integument: No dryness, pallor, yellowish discoloration, clubbing of

fingers, or hair loss/excessive hair

c.

HEENT:
o

Head: No syncope or history of head trauma was reported.

Eyes: (+) blurring of vision. No double vision, excessive lacrimation,

eye redness nor photalgia were reported. The patient does use reading
glasses.

Ears: No hearing difficulty, tinnitus, vertigo, infections or discharges.

Nose and Sinuses: No reports on epistaxis, discharge, itching, nasal

stuffiness, or itching.

Mouth and throat: No mouth sores, toothache, sore throat,

hoarseness of voice or dysphagia was reported.

Neck: No neck pain, lump, nor stiffness.

d.

Respiratory: No shortness of breath, cough, colds or hemoptysis was

reported

e.

Cardiovascular: No chest pain, palpitations, easy fatigability, orthopnea,

cyanosis, or paroxysmal nocturnal dyspnea was reported.
o

Peripheral vascular: No reports of leg cramps, edema or varicose

veins.

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
f.

Gastrointestinal:
No
abdominal
pain,
changes
in
appetite,
hematochezia, hematemesis, diarrhea, or excessive belching/passing of
gas.

g.

Renal: There are no dysuria, nocturia, incontinence, urinary urgency,

gross hematuria, urinary retention, reduced caliber of force of stream,
hesitancy, or dribbling during urination.

h.

Genitalia: No pain, itching, or discharge, swelling or ulcers was reported.

i.

Hematologic: There is no pallor, easy bruising, or bleeding.

j.

Musculoskeletal: No muscle pain, backache, stiffness, joint swelling or

joint pain was reported.

k.

Endocrine: No polyuria, polydypsia, polyphagia, excessive sweating, or

heat/cold intolerance reported.

l.

Neurologic: No reports on history of weakness, tremors, seizures, or

memory loss.

m.

Psychiatric: No hallucination, depressed mood. Not anxious.

Physical Examination:
General Survey:
Patient is awake and cooperative, properly oriented to surroundings, time,
place and situation, with appropriate affect and mood. There were no apparent
signs of cardiorespiratory distress.
Vital Signs:
Blood Pressure: 100/60 mmHg sitting, right arm
Heart Rate: 67 beats per minute, regular
Respiratory Rate: 18 breaths per minute, regular
Temperature: 36.8C
Anthropometric Measurements: (not assessed)

Skin, Hair and Nails:

Skin is generally warm and dry, and with good turgor. (+) multiple, welldefined, erythematous plaques, topped with crusting, excoriation and ulcers, at the
distal aspect, medial leg.
Hair color is black, with average texture, minimal flaking and does not have
any pattern of hair loss. No skin discoloration, lumps, scaling nor lesions on the

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
scalp. Nails do not exhibit clubbing and there is absence of cyanosis. Nail beds were
pinkish.
Head:
Face is symmetric, without deformities, involuntary movements, tender areas,
edema or masses.
Eyes:
Eyes are bilaterally symmetrical, with no inward or outward deviation.
Eyebrows are evenly distributed. There is no scaliness of the eyebrows. Eyelids do
not have edema and lesions. There are neither widening nor narrowing of the
palpebral fissures. Visual fields full by confrontation. Palpebral conjunctivae are
pinkish without discharge and lesions; anicteric sclerae, without discharge.
Ears:
Ears are symmetrical with no deformities, lumps and lesions in auricle. No
discharge, tenderness, foreign bodies, redness and swelling were noted.
Nose:
Symmetrical with no external deformities. Nasal mucosa is pinkish and has no
swelling, bleeding and exudates. No swelling on the turbinates. No septal deviation,
inflammation and perforation. No obstruction, congestion, ulcers or discharge
Mouth and Throat
Lips are pinkish without cracking; there were no lumps, ulcers, and scaliness.
Oral mucosa is pinkish, without ulcers, white patches and nodules. Gums are pinkish
with no swelling or bleeding. Tongue is pinkish, and in the midline. Uvula is in the
midline. The tonsils were intact, with a grade of 0, and not inflamed. The posterior
pharyngeal wall is non-hyperemic. Also, no exudates were found.
Neck
Trachea is in midline. Neck with full ROM. No tenderness, no masses or scars.
Lymph nodes are not palpable. Thyroid is non-palpable. No palpable enlargement of
the thyroid gland.
Chest and Lungs
Chest wall is symmetrical with prominent ribs. There is no retraction of
interspaces on inspiration, nor use of accessory muscles of breathing upon
inspection. Transverse diameter is greater than the anteroposterior diameter.
Upon palpation, there are neither tender areas nor palpable mass on the chest.
Respiratory expansion at the 10th rib is symmetric. The left and the right lungs are
equally resonant upon percussion. During auscultation, breath sounds are
bronchovesicular. There is no bronchophony, egophony, whispered pectriloquy,
crackles, stridor, ronchi, nor wheezes.

Cardiovascular

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Patient has adynamic precordium. There is no precordial bulge or heave. The
chest area is free of lesions or deformities. Upon palpation, there is no thrill or
friction rub. Point of maximal impulse is felt on the 4th intercostal space, exactly at
the left midclavicular line.
On auscultation, heart sounds were of medium intensity with a normal rate
and regular rhythm. S1 is best heard at the apex while S2 is loudest at the base.
There are no S3, S4, murmurs, or pericardial friction rub.
Peripheral Vascular:
There is no cyanosis, varicose veins or digital clubbing of fingers. No pretibial
edema
Abdomen:
The abdomen is flabby. There are no scars, lesions, striae or dilated veins. The
umbilicus is at the midline and not protruding. Flanks were not bulging. There are no
irregular contours, discoloration or bulges. Peristalsis and aortic pulsations were not
visible.
Normoactive bowel sounds upon auscultation. There were no bruit, friction rub
or succussion splash. The abdomen was tympanitic. No muscle tenderness upon
palpation, and there is no shifting dullness.
Liver: Liver span dullness is 10 cm at the RMCL. Liver edge is palpable, with
smooth contour and without tenderness at full inspiration.
Spleen: The spleen is not palpable.
Kidneys: The kidneys are not palpable, no costovertebral angle tenderness.
Neurological:
Appearance and Behavior:
Patient appears to be alert, and oriented to time place and person. He
is able to make eye contact during the interview. He is dressed properly and
is sitting down. There were no mannerisms or tics noted.
Speech and Language:
The speech is of adequate speed, spontaneous, soft with moderate
loudness. Patients spoken language can be generally understood.
Mood:
Patient is in euthymic mood.
Thoughts and Perception:
Thought process and content is coherent and appropriate respectively.
There were no hallucinations, delusions or illusions.

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Mental Status:
Using the Folstein Mini-Mental Status Exam, the patient scored 28 out
of 30. In the classification, where a score 23-30 is normal, 19-23 is borderline,
and <19 is impaired, the patient has mental decline. The outcome of each
part of the test is indicated below:
Criteria
Orientation
Name: Season/date/day/month/year (1point each)
Name: Hospital/floor/city/province/country (1 point each)
Registration
Identify three objects by name and ask patient to repeat (1 point
each)

Score
5
5
3

Attention and Calculation

Serial 7s (1 point each)

Recall
Recall the three objects presented earlier (1 point each)

Language
Name pencil and watch (1 point each)
Repeat No ifs, ands, or buts (1 point)
Follow a three-step command (1 point for each command)
Write close your eyes and ask patient to obey written command
(1 point)
Ask patient to write a sentence (1 point)
Ask patient to copy a design

2
1
3
1
1
1

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Cranial Nerves:
Cranial Nerve

Assessment

Olfactory (I)

Not assessed

Optic (II)

Light perception present.

Visual acuity was not assessed.
Visual fields full by confrontation.

Optic
(II), Pupils equally reactive to direct and consensual light
Oculomotor (III)
reflex
Oculomotor (III),
Trochlear (IV),
Abducens (VI)

EOMs are full and equal

No ptosis, intact ocular muscle, no nystagmus and no
lid lag.

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Trigeminal (V)

Motor Can move jaw from left to right side with

symmetry and without difficulty (temporal and
masseter muscle strength intact).
Sensory Can correctly identify pricking sensation on
forehead (ophthalmic), cheek (maxillary) and jaw
(mandibular). Corneal reflex intact on both eyes

Facial (VII)

No facial asymmetry

Vestibulocochlear
(VIII)

Able to hear rubbing of fingers on both ears at a

distance of 5 inches.

Glossopharyngeal
(IX), Vagus (X)

The uvula was in midline

Positive gag reflex
The voice lack hoarseness and nasal quality.

Spinal Accessory
(XI)

The patient was able to shrug his shoulders (trapezius

muscle) as well as turn his head from side to side
(sternocleidomastoid muscle). No fasciculations,
shoulder droops and displaced scapula.

Hypoglossal (XII)

Tongue is symmmetrical and in midline. The patient

was able to protrude his tongue, move it side by side,
in and out and upward and downward.

Motor Examination:
Upon inspection, the patient has symmetric muscle bulk of proximal
and distal muscles of both upper and lower extremities. No atrophy of
muscles. No clonus, no fasciculations. No involuntary movements (tics,
chorea, tardive dyskinesia, athetosis, ballism). No seizures, tremors, spasm.
Arms and legs can be extended throughout the range of movement. Palpation
of muscle groups like biceps, triceps, and deltoid were non tender.
Muscle Tone:
No rigidity or spasticity. No flaccidity. Normotonic on all four extremities
on all major joints upon passive range of movement.
Coordination and Gait:
No difficulties in starting and halting walking. No loss of coordination,
difficulty on turning, staggering or shuffling gait.
Patient was able to do rapid alternating movements and finger-to-nose
test.
Sensory:
100%
100%

100%
100%

Motor:
5/5
5/5

5/5
5/5

Reflex:
++
++

++
++

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Assessment:
Biomedical:
Mixed Wound Infection (probably bacterial and fungal), distal area, left leg
Diabetes Mellitus Type 2, uncontrolled
Family Classification:
Structure: Extended Family
Residence: Neolocal
Class Pattern: Lower class
Set-up: Democratic
Family Life Cycle: Launching Family
Trajectory of Illness: Stage 3: Early Adjustment to Outcomes Recovery
Plan:
DM diet, increase oral fluid intake
For repeat FBS, HbA1c, TC, TG, HDL, LDL, and Creatinine
Medications:
o Triamcinolone acetonide 0.1% cream (Triderm) BID
o Cetirizine 10 mg/tab BID for 5 days
o Metformin 500 mg/tab BID
o Multivitamins capsule OD
For vaccination c/o Baluarte HC:
o Pneumococcal
o Hepatitis B
o Influenza
Exercise at least 1 hour per day
Foot care and hygiene
Advised consult to an Ophthalmologist for evaluation and management of his
blurring of vision
Advised regular check-up to health-care provider for his DM
Advised
Family Classification:
Structure: Extended
Socio-Economic: Low socioeconomic class
Family Set-up: Democratic
Residence: Neolocal
Stage in the Family Life Cycle: Launching Family

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Family Roster:
Name
Age/Sex

Relationship
to Index
patient

Occupatio
n

Genoveva

56/F

Wife

Vendor

Ryan

33/M

Son

Raymark

19/M

Son

Marjean

11/F

Granddaughte
r

Pedicab
driver
StudentCollege 3rd
yr
Student
6th grade

Breakdown of Monthly Income and Personal

Daily
Total Family Income
P 550.00
Household Expenses
Food
P 175.00
Toiletries
(monthly basis)
Electricity
None
Water Bill
None
P 20.00
Medication
P 20.00/ person
Personal
expenses

Highest
education
al
Attainmen
t
Highschool
graduate
Highschool
graduate
Highschool
graduate

Income

P 350/day
P 200/day
N/A
N/A

Expenses:
Monthly
P 16, 500.00
P 5,250 + 6,000 (budget for food
business)
P 150.00
P 600.00
P 600.00

P 12,600.00
Emergency Money
P 3,900.00
** Total family income is varied. Values encoded were computed based on
an average basis.
Family Mapping:

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Family Timeline:

 Joana married Reynaldo

Lamberto was diagnosed to have DM type 2
Jacqueline married Alvin and transferred to Tondo
Teresa married Orlando and moved to Pangasinan
Birth of their 11th child, Raymark via NSD
Birth of Rommel via NSD
Gina married Reynaldo and moved to Mindoro
Birth of Jacqueline via NSD
Birth of Lamberto Jr. via NSD
Birth of Jennifer via NSD
Birth of Joana via NSD
Birth of Raul ; Lamberto started to open food stall and sari sari store
Birth of Irene via NSD
Birth of Ryan via NSD
Birth of Teresa via NSD
Birth of Gina, their first born via NSD
Lamberto and Genoveva got married, started to live together in
Intramuros, Manila
Birth of Lamberto (Index patient)

2013

2012

2011

1997

1995

1993

1991

1988

1986

1985

1983

1980

1979

1977

1975

1974

1973

1954

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Family APGAR:
Index patient: Lamberto Sr.
APGAR
1
A
Akoy nasisisyahan dahil
nakakaasa ako ng tulong
sa aking pamilya sa oras
ng problema
P
Akoy nasisisyahan sa
paraang
nakikipagtalakayan sa
akin ang aking pamilya
tungkol sa aking
problema
G
Ako ay nasisisyahan at
ang aking pamilya ay
tinatanggap at
sinusuportahan ang aking
nais na gawin patungo sa
mga bagong landas para
sa aking ikauunlad
A
Akoy nasisisyahan sa
paraang ipinadama ng
aking pamilya ang
kanilang pagmamahal at
nauuunawaan ang aking
damdamin katulad ng
galit, lungkot at pag-ibig.
R
Akoy nasisisyahan at
ang aking pamilya at ako
ay nagkakaroon ng
panahon sa isat isa
TOTAL

PALAGI

PAMINSANMINSAN

HALOS
HINDI

8 points
APGAR 2
Sino-sino ang nakatira sa inyong tahanan? Paano ang iyong
relasyon?
Pangalan
Relasyon
Mabuti
Hindi
Hindi mabuti
gaanong
mabuti
Genoveva
Asawa
X
Ryan
Anak
X
Raymark
Anak
X
Marjean
apo
X

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Kung hindi ka nakakahingi ng tulong sa iyong pamilya, kani-kanino ka
humihingi ng tulong? Paano ang inyong relasyon?
Pangalan
Relasyon
Mabuti
Hindi
Hindi mabuti
gaanong
mabuti
Freddie
Kaibigan
X
Arturo
Kaibigan
X
Genoveva: Wife
APGAR
PALAGI
PAMINSANHALOS
1
MINSAN
HINDI
A
Akoy nasisisyahan dahil
nakakaasa ako ng tulong
sa aking pamilya sa oras
ng problema
P
Akoy nasisisyahan sa
paraang
nakikipagtalakayan sa
akin ang aking pamilya
tungkol sa aking
problema
G
Ako ay nasisisyahan at
ang aking pamilya ay
tinatanggap at
sinusuportahan ang aking
nais na gawin patungo sa
mga bagong landas para
sa aking ikauunlad
A
Akoy nasisisyahan sa
paraang ipinadama ng
aking pamilya ang
kanilang pagmamahal at
nauuunawaan ang aking
damdamin katulad ng
galit, lungkot at pag-ibig.
R
Akoy nasisisyahan at
ang aking pamilya at ako
ay nagkakaroon ng
panahon sa isat isa
TOTAL
8 points
APGAR 2
Sino-sino ang nakatira sa inyong tahanan? Paano ang iyong
relasyon?
Pangalan
Relasyon
Mabuti
Hindi
Hindi mabuti
gaanong
mabuti
Lamberto
Asawa
X

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Ryan
Raymark
Marjean

Anak
Anak
apo

X
X
X

Kung hindi ka nakakahingi ng tulong sa iyong pamilya, kani-kanino ka

humihingi ng tulong? Paano ang inyong relasyon?
Pangalan
Relasyon
Mabuti
Hindi
Hindi mabuti
gaanong
mabuti
** Other members were not at home during the time of Interview
OVERALL SCORE: 8 Highly Functional Family
SCREEM:
Social

Cultural
Religious

Economic

Resource
Social interaction is
evident among family
members as well as with
their neighbors
The family is proud to be a
Filipino family
The family is satisfied with
their religious beliefs, all
of the members are
practicing catholic faith

Although the family

professes faith, they
seldom visit church and
attend religious
gatherings

The family is economically

stable and has ability to
meet financial demands
during times of
emergency

Educational

Medical

Pathology

Even if the patient knows

that he has DMT2 and was
educated to have lifestyle
change and intake of
maintenance medication,
he still has poor
compliance. The family is
seemingly closed minded
in terms of health
education as they do not
attend seminars or forum
sponsored by the health
center
Health care is accessible
to the family (Baluarte

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
Health center)
The family seek consult
whenever one member is
sick
Pychosocial Data:
Breadwinner:
Lamberto is the primary earner in the family. His wife and son
helps in the household
Expenses.
Authority: The family is patriarchal however, the index patient respects his family
members decisions especially that all of his children are adults and
most of them have their own family.
Primary Caregiver:

Genoveva (wife) is the primary caregiver in the family.

Familys Present Priorities: Education for Raymark, their food business and
maintaining health among the family
Family Illness Trajectory:
Stage IV Early adjustment to outcomes Recovery
The index patient was diagnosed to have Diabetes Mellitus type 2 two years
ago and had since been advised to take Metformin 500mg OD, however patient is
non-compliant with his medication and now has complaint of itching on his left
lower leg but tends to disregard his condition and just cope with it.
Health Status of Family Members:
NAME
AGE/SEX
Lamberto
60/M

FINDINGS
S> (+) itching of left foot, (-) numbness, (-)
changes in color of the extremities
O> 100/60--6718--36.8
Conscious, coherent, not in distress
Dirty sclerae, pink palpebral conjunctiva,
no naso-aural discharge, no CLAD
Symmetric chest expansion, no retractions,
clear breath sounds
AP, normal rate and regular rhythm
Flabby
abdomen,
soft,
non-tender,
normoactive bowel sounds
Full equal pulses, grossly normal
(+) multiple, well-defined erythematous
plaques topped with crusting, ulceration
and excoriation, distal aspect, medial left
leg.
A> Mixed Wound Infection
DMT2, uncontrolled
P> DM diet, inc. OFI

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Genoveva

56/F

For FBS, HbA1c, TC, TG, HDL, LDL,

Creatinine
Meds:
1. Triderm cream BID
2. Cetirizine 10 mg BID BID for 5 days
3. Metformin 500 mg BID
For vaccination c/o Baluarte HC:
a. Pneumococcal
b. Hepatitis B
c. Influenza
Exercise at least 1 hour per day
Foot care and hygiene
Advised consult to an Ophthalmologist for
evaluation and management of his blurring
of vision
Advised regular check-up to health-care
provider for his DM
Advised
S> patient had no subjective complaints
except for cloudy vision on her right eye,
previously
diagnosed
as
Immature
Cataract, OD (Manila Doctors Hospital,
2012). Non-smoker, non-alcoholic beverage
drinker. No history of familial disease. (+)
menopause at the age of 44. No history of
gynecologic problems.
O> 120/80 78 18 37.0 C
Conscious, coherent, not in distress
Dirty sclerae, pink palpebral conjunctiva,
no naso-aural discharge, no CLAD
Symmetric chest expansion, no retractions,
clear breath sounds
AP, normal rate and regular rhythm
Flabby
abdomen,
soft,
non-tender,
normoactive bowel sounds
Full equal pulses, grossly normal
A> Essentially normal PE at the time of
examination
Immature Cataract, OD
P> advised low salt, low fat diet to prevent
development of Hypertension
Adequate fluid intake
Advised daily exercise
Medications:
1. Multivitamins + Ferrous Sulfate capsule,

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
OD
Advised consultation to an ophthalmologist
for evaluation and management of cataract
Well advised
Ryan
Raymark
Marjean

33/M
19/M
11/F

Not seen at the time of interview

Not seen at the time of interview
Not seen at the time of interview

Family Wellness Plan:

PRIMARY PREVENTION
Lamberto,
60/M

Regular exercise
Annual
physical
examination
Hepatitis
B,
Pneumococcal
and
Influenza vaccines
Vitamin
supplementation
Personal hygiene
Dental hygiene
Health
Education
(Balanced
at
appropriate
diet,
accident
exposure,
polypharmacy)
Accident prevention

SECONDARY
PREVENTION
Annual
BP
monitoring
Annual
fecalysis
with occult blood
testing
Annual urinalysis
Annual lipid profile
determination
Annual Creatinine
and
GFR
determination
Height and weight
check (BMI)
Annual Audiometric
Exam

TERTIARY
PREVENTION
DM diet
For
FBS
every
2-4
weeks
until
blood sugar
is controlled;
for
HbA1c
every
3-6
months
Triamcinolon
e cream BID
to
affected
area
Cetirizine 10
mg BID for 5
days
Metformin
500 mg BID
Refer
to
Department
of

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Genoveva,
58/F

Ryan,
33/M

Annual
Physical
Examination
Regular
ageappropriate exercise
Hepatitis
B,
Pneumococcal
and
Influenza vaccines
Vitamin
supplementation
Personal hygiene
Dental hygiene
Health
Education
(Balanced
at
appropriate diet [DM
diet],
accident
exposure,
polypharmacy)
Accident prevention
Dental hygiene and
monitoring
Education on proper
hygiene: bathing every
day, nail care, hand
washing,
family
planning
Assessment
and
advise
to
quit
smoking,
consume
alcoholic
drink
moderately
Advise
to practice
safe sex
Promote
healthy
lifestyle and diet
Weight monitoring
Address
concerns
about
marital
and
family relationships

Annual BP
monitoring
Annual FBS, Lipid
Profile
determination
Annual Eye checkup
Height and weight
check (BMI)
Annual Audiometric
Exam
Annual Fecalysis
and Occult Blood
Annual Chest X-ray
Annual breast
examination
Annual Pap Smear
and Pelvic Exam
BP
monitoring
annually
Fecalysis
and
urinalysis may be
done annually
CXR annually
Annual PE should
be done
During times of
illness, advise to
seek
consult
immediately
and
encourage
family
participation

Ophthalmolo
gy for further
evaluation
and
comanageme
nt
of
the
blurring
of
vision
N/A

N/A

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Raymark,
19/M

Marjean,
11/F

Advise proper use of

OTC medications
Health
education:
Sanitation
issues,
consumption of junk
food,
accident
prevention,
sexual
issues and health risks
Dental hygiene and
monitoring
Education on proper
hygiene: bathing every
day, nail care, hand
washing,
family
planning
Assessment
and
advise
to
quit
smoking,
consume
alcoholic
drink
modetately
Advise
to practice
safe sex
Promote
healthy
lifestyle and diet
Sexual
development
and
nutrition
monitoring
Address
concerns
about peer pressure,
parental
relationship
and courtship
Advise proper use of
OTC medications and
possible drug allergies
Health
education:
Sanitation
issues,
consumption of junk
food,
accident
prevention,
sexual
issues and health risks
Dental hygiene and
monitoring
Education on proper
hygiene: bathing every
day, nail care, hand
washing

BP
monitoring
annually
Hearing
acuity
done atleast once
PPD may be done
as screening for
PTB
Fecalysis
and
urinalysis may be
done annually
CXR annually
Annual PE should
be done
During times of illness,
advise to seek consult
immediately
and
encourage
family
participation

BP
monitoring
annually
Teach
breastself
examination at age
9
Hearing
acuity

N/A

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

Immunization
based
on EPI
Assessment
and
advise about accident
exposure
Promote
healthy
lifestyle and diet
Motor
development
and
nutrition
monitoring
Address
learning
difficulties
and
language skills
Address
concerns
about
moral
and
emotional
development
Vitamin
supplementation and
assess drug allergies
Health
education:
Sanitation
issues,
consumption of junk
food,
accident
prevention,
sexual
issues and health risks

done atleast once

Visual
acuity
determination
starting at age 9,
done annually
PPD/ BCG direct
may be done as
screening for PTB
Fecalysis
and
urinalysis may be
done annually
Annual PE should
be done
During times of illness,
advise to seek consult
immediately
and
encourage
family
participation

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

How to get there?

Patients Household is found by

passing 3 houses

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
along this street

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

The index
patient,
Lamberto Sr.
with his

With the
interviewers
Mrs. Genoveva
Austria