Community Gr

Community Grandrounds Tan, Kathryn; Tan, Katrina; Tan, Kent; Tan, Mark; Tan, Reina; Tanchoco, Luisa; Tayag, Erin

Clinical assessment

General Data Name: R.S. ■ Age: 6 months old ■ Sex: female ■ Barangay Sto. Nino, Sapang Palay ■ Informant: Mother (Criselda) ■ Reliability: 90% ■

Chief complaint

Diarrhea

History of Present Illness Change in milk formula

2 weeks PTC 2 days PTC

4 episodes of watery stools No fever, hematochezia, tenesmus, vomiting, anorexia and weight loss Consultation

ROS ■

Skin – – –

■

(-)Rashes (-)Color changes (-)Pigmentation

■ ■

Neck – (-) masses

■

Cardiovascular – (-) cyanosis

Respiratory: – (-) difficulty of breathing – (-) cough

HEENT – (-)Colds – (-)Ear discharge

■

■

■

Urinary – (-) frequency Nervous: – (-) vomiting – (-) convulsions – (-) weakness or paralysis Hematopoietic: – (-) pallor – (-) bleeding manifestations

Gestational history 17 y/o ■ G1P1 (1-0-0-1) ■ healthy ■ good nutrition ■ no infections ■ no intake of drugs ■ 9 months gestation ■

Birth History Full term ■ NVSD ■ Physician attended at birth ■ Birth weight: 6.8 lbs ■ No complications during birth ■

Neonatal Condition spontaneous respiration (cry) ■ acyanotic ■ no pallor or jaundice ■ no convulsions ■ no hemorrhage or feeding difficulties ■

Feeding History ■

Breast fed: (form birth to present) – –

Interval: every 3-4 hours Duration: 40 mins. – 1 hr.

Mixed (Bottle fed and breastfeeding) at 5 months ■ Present feeding: infant cereal mix (cerelac) and bottle fed ■

Growth and Development: Lift head on prone: 2 month ■ Smiles socially: 2 months ■ Visual tracking: 2 months ■ Reaches for toys: 4 months ■ Rolls over: 5 months ■

Growth and Development: ■

Developmental Reflexes – – – –

Moro: Absent Palmar and Plantar Grasp: Present Rooting and sucking: Absent Tonic Neck Reflex: Absent

Immunizations BCG – Nov. 16, 2006 (last dose) ■ DPT – Dec. 12, 2006 (last dose) ■ TOPV – under aged ■ Measles- under aged ■ MMR – under aged ■ Hepa B – Dec 12, 2006 (last dose) ■

Past illness (-) asthma ■ (-) allergies ■ (-) injuries ■

Family History ■

■ ■

Parents: – Father: Ryan, 24 y/o, with permanent occupation (assistant cook), healthy – Mother: Criselda, 17 y/o, housewife, healthy (+) Asthma: Uncle (-) heart disease, HPN, DM, Cancer, TB, allergies

PE on consultation

General: Awake, alert ■ Not in distress ■ No signs of dehydration ■ Well- developed ■

Vital signs: Temp: 37.2 ■ PR: 140 beats/min regular ■ RR: 40 breaths/min regular ■

Anthropometric measurements Ht: 62.1 cm ■ Wt: 6 kgs ■ HC: 39 ■ CC: 36.5 ■

Nutritional Assessment WFA= 6 Kgs x100 = 83% mild PEM 7.2Kgs ■ HFA= 62.1 cm x 100 = 96% Normal 65 cm ■ WFH = 6 Kgs x 100 = 97% Normal 6.2 ■

Physical Examination ■

Skin: – – –

■

Soft, warm to touch Good skin turgor No active dermatoses

Head – equal distribution of black and smooth hair w/o lice or nits – skull normocephalic, atraumatic, anterior fontanel open (diamond shaped), posterior fontanel closed

■

Eyes – pink palpebral conjunctiva, anicteric sclerae, pupils ERTL

■

Ears: – (-) tragal tenderness, (-) discharge

Physical Examination ■ Nose:

– septum midline, (-) discharge ■ Oral

Cavity:

– pink and moist buccal mucosa, nonhyperemic posterior pharyngeal walls, (-) tonsillar enlargement (-) tonsillar exudates ■ Neck

(lymph nodes, size, location, number): – supple neck (-) palpable cervical lymph nodes

Physical Examination ■

Lungs: – symmetrical chest expansion, (-) retractions, clear breath sounds

■

Heart: – adynamic precordium, no lifts heaves or thrills, AB 4th ICS MCL, base: S2>S1, apex: S1>S2, no murmurs

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Abdomen: – globular, soft, normoactive bowel sounds, nontender, no masses, tympanitic, liver span 3 cm below right costal margin MCL

■

Extremities: – pulses regular, full and equal, (-) edema (-)

Differential diagnosis

Differentials ACUTE DIARRHEA

INFECTIOUS - Bacterial - Viral - Parasitic

NON-INFECTIOUS - Anatomic - Malabsorption - Endocrinopathies - Food Poisoning - Neoplasms

Differentials (least to most likely) ■

Neoplasm - Neuroblastoma, Ganglioneuroma, Pheochromocytoma, Carcinoid - not considered because diarrhea was of acute onset, (-) family history, no other accompanying symptoms such as abdominal mass, distention, vomiting, weight loss and extraintestinal manifestations

Differentials ■

Anatomic causes - Malrotation - no episode of bilious emesis or recurrent abdominal pain - Intestinal duplication – no palpable mass or vomiting - Hirschprung disease – no reported delayed passage of meconium

Differentials ■

Malabsorption Syndrome - no family history of malabsorption disorders; abdominal distention; failure to thrive; pale, foul-smelling, bulky stools; weight loss; muscle wasting.

Differentials ■

Food Poisoning - patient has only been breast- and formula-fed since birth - no reported episode of accidental ingestion of toxic compounds

Differentials ■

Infection - no fever, cramping abdominal pain, or vomiting - diarrhea was not profuse and appeared only after the patient was bottle-fed

Differentials ■

Cow’s Milk Intolerance - most likely consideration - usually in infants 6 months and below who have been introduced to formula feeding - protein in cow’s milk is the most common offending agent

Clinical Impression Non-infectious diarrhea d/t transient milk intolerance Mild PEM

Pathophysiology

Diarrhea An increase in stool volume and frequency of defecation ■ Defecation of more than 10g/kg/day in infants and children wherein the stools follow the shape of the container ■ Stool is usually watery and loose ■ It is the most common clinical sign of gastrointestinal disease ■

Diarrhea Diarrhea occurs when insufficient fluid is absorbed by the colon ■ Absorption of water in the intestines is dependent on adequate absorption of solutes. If excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhea will result. ■

Osmotic Diarrhea ■

2 mechanisms: 1. Ingestion of a non-absorbable solutes – usually a carbohydrate or a divalent ion, e.g. sorbitol or manitol, epson salt and some antacids 2. Malabsorption – inability to absorb certain carbohydrates, the most common would be lactose intolerance

Treatment ■

Continue milk formula

Dietary Prescription 6 months old / Female ■ TER = weight @P50 x Calorie (kcal/kg) ■ = 7.2 kg x 90 kcal/kg (throughout the first year of life) ■ TER = 648 kcal/ day ■

Dietary Prescription Distribution of TER into carbohydrates, proteins and fats by percentage method. Nutrient: Carbohydrates = 60% of TER(648)= 388.8kcal/day Proteins= 15% of TER(648)= 97.2kcal/day Fats= 25% of TER(648)= 162 kcal/day

Dietary Prescription Kcal converted to grams: Carbohydrates: 388.8kcal/ 4= 97.2 gm. Protein: 97.2/ 4= 24.3 gm. Fats: 162/ 9= 18 gm. Prescription: 650 cal 95 gm 25 gm 20 gm TER CHO CHON FAT

FAMILY ASSESSMENT

Family Genogram

Soriano Family address

April 27,2007

March 1990

Honorio 55

Lydia 49

Renato 39

Christine 39

-----------

Christian 21

Henry 29

Lilibeth 27

Joseph Ryan Sitangco 24

Criselda 17

Raymart 16 Legends: - Index Patient

Josea Elisa

Riyana

9 months months

6

- Diarrhea

- Asthma

- Bad relationship - good relationship - very good relationship

Map

San Martin de Porres SocioMedical Center

Family Profile Name

Age

Sex

Civil status

Relation to head of family

Educational attainment

Staying with family?

Ryan

24

M

Single

Breadwinner

HS

Yes

Criselda

17

F

Single

Partner

HS

Yes

Ryana

6 mos

F

Single

Daughter

-

Yes

Honorio

55

M

Married

Father

HS

Yes

Lydia

49

F

Married

Mother

HS

Yes

Roles and Function Breadwinner to Ryana: Ryan ■ Decision Maker to Ryana: Criselda ■ Caregiver to Ryana: Criselda ■

Family Structure and Function Type of Family

Extended

Ordinal Position of Index Patient First and only child of Ryan and Criselda Parent Child Interaction

Active relationship of mother only to the child

Social Class Pattern

Low Income

Family Set-up

Democratic

Family Life Cycle

Family with young child

No. of Family Members

7 (3+4)

Religion

Catholic

Family Lifeline March 1990 – Criselda’s parents separated ■ July 2005 – started relationship ■ September 2005 – Criselda ran away from home and lived in together ■ Feb 2006 – Criselda got pregnant ■ April 2006 – Moved from Manila to Bulacan ■ Oct 2006 – Birth of Ryana ■

Family Life Cycle Single Parent with Young Children First Order Changes or Tasks Involved: ■ Achieving independence from in-laws ■ Setting up a decent home for themselves ■ Assuring good health for the child ■ Assuring basic education for the child

Family Life Cycle

■ ■ ■ ■

Second Order Changes in Family Status Required to Proceed Developmentally Meeting predictable and unexpected costs of family life Creating and maintaining effective communication system in the family Maintain good relationship between husband and wife Establish better bond between parentsin-law and daughter-in-law

Problems Encountered ■

Medical – diarrhea due to change in formula of Ryana – Medical problems that may relate to poor hygiene – Medical problems related to environmental factors ■

Insect bites

Problems Encountered ■

Emotional and Social – Financial difficulties – insufficient earnings of the husband (Ryan) as an assistant cook – Career limitations brought about by low educational level – Emotional stress and doubt due to lack of acknowledgement of Ryana and Criselda in the family – Lack of time spent together as a family

Economic Profile

Monthly Allocation of Ryan’s Income ■ ■

■

■

Pampers 50% Milk and Cerelac 30% Gamot at kalusugan 15 % Others 5% – Water 2.5% – Rice 2.5%

■ ■

Damit 0% Ipon 0%

Pampers

15%

5%

50% 30%

Milk and Cerelac Gamot & Kalusugan Atbp

Monthly Allocation of Honorio’s Income ■ ■ ■ ■ ■

Pagkain 70% Kuryente 20 % Tubig 10% Damit 0% Ipon 0%

15%

Pagkain Kuryente Tubig

30% 50%

Economic Profile: Sources of Income Name

Occupation

Monthly Income

Other Sources of Income

Honorio Driver

P10,000 /month -

Ryan

P 2800/month

Total

Assistant cook

P 12,800/month

-

FLOOR PLAN window

window

SALA

BED entertainment center

door

door

LAUNDRY

KITCHEN

Washing Machine

BATHROOM

BED

Ref

TABLE

Divider

Environmental Profile Dwelling Unit Type No of Bedrooms Appliances

1 house, bungalow type; owned by grandmother Concrete and wood 2

Cleanliness/Order Ventilation

TV, VHS, radio, electric fan, refrigerator, electric flat iron, washing machine Moderately clean Poorly ventilated

Lighting

Fluorescent bulbs

Water

Tap water

Environmental Profile Drinking Water Toilet

Commercial purified water for Ryana, tap water “De buhos”

Drainage

Open

Garbage

Incinerated

Animals

Dogs, chickens, pigs

Vermin/insect type

Cockroach, mosquito, rats

Vermin/insect control

Poor

Neighborhood

Poor interpersonal relationship

Pictures

Main gate

Pathway to the house

Front

Animals in the backyard

Source of water

Drainage

Front door

Living room

Bedrooms

Dining room/ kitchen

Bathroom

Toilet

With baby Ryana and mommy Criselda

With grandmother and neighbors

Tools of Family Assessment APGAR SCREEM

APGAR Ryan

Criselda

A

Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema

1

1

P

Ako’y nasisiyahan sa paraang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema

2

2

G

Ako’y nasisiyahan at ang aking pamilya ay tinatanggap at sinusupotahan ang akong nais na gawin patungo sa mga bagong landas para sa aking ikauunlad

1

1

A

Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya ng aking pamilya ang kanilang pagmemehal at nauunawaan ang aking damdamin katulad ng galit, lungkot, at pag-ibig

0

0

R

Ako’y nasisiyahan dahil ang aking pamilya at ako ay nagkakaroon ng panahon para sa isa’t isa

1

1

5

5

Total

APGAR 1.Sinu-sino ang mga nakatira sa inyong tirahan? Ano ang inyong relasyon? Pangalan

Relasyon

Kasarian

Ryan

Asawa

Lalaki

Criselda

Asawa

Babae

Ryana

Anak

Babae

Honorio

Biyenan

Lalaki

Lydia

Biyenan

Babae

Mabuti

Di gaanong mabuti

Di mabuti

APGAR 2. Kung hindi ka nakakahingi ng tulong mula sa iyong pamilya, kanino ka humihingi ng tulong? Anong uri ng tulong? - They do not ask help from friends or neighbors a. ) In the future, what is the family’s primary goal? - Their primary goal is to achieve independence from in-laws and get a more financially stable job.

APGAR 2. b.) Do all the members work together

towards these goals/desires? How? If not, what seems to be the hindrance for working together? - No, the mother has no job and can’t help in achieving independence. The grandmother is not supportive because she is disappointed with her son for having a family at such a young age.

APGAR c.) Is there any history of alcoholism, gambling, drug abuse/dependency, domestic violence? Has something been done to address this problem? - None of the family members are involved in alcoholism, drug abuse/dependency, or domestic violence d.) To what organization does the family belong to? - El shaddai

SCREEM Parameter Social

Cultural

Religion

Strength

Weaknesses

-Good relationship with -Poor communication with neighbors family (in-laws) -Absence of rivals -Husband is away from family for 5 days - Absence of beliefs/practices that are unacceptable in our culture - Religion of the family: El Shaddai

SCREEM Education - Both parents literate

- Both parents only finished till high school

Economic - Regular source of income

- Income is not enough to support the family

Medical

-Everybody except Ryana are apparently healthy -Ryana has check-ups regularly

- The rest of the family does not have regular medical check-ups

COMMUNITY ASSESSMENT

Community Assessment Positive points There are no piles of garbage in the area. ■ There is no rivalry between community members. ■

Community Assessment Negative points ■

■ ■ ■

The pathways leading to their houses are dangerously steep, and can become slippery and muddy during the rainy season. The community uses open drainage system. Incineration of garbage which adds to the pollution. Many stray dogs

MINUS (-) POINTS Problem

Recommendations:

■Source

■Boiling

of drinking water

■Improper

segregation and incineration of waste ■Lots

of mosquitoes in the area

Educate on proper waste management ■Teach on how to recycle and make compost ■Cover stagnant water ■

■ ■Steep,

uncemented road

of the water

Mosquito net, insect repellant

■Caution

■Muddy

area especially during rainy season

■Caution

■Many

■Rabies

■Use

stray dogs

of open drainage system

vaccination

cover drainage, practice good hygiene ■

Family health care plan

Family health care plan TYPE OF CARE

Medical

FAMILY MEMBER

PROBLEM

Ryan

none

Criselda

none

RECOMMENDATIO N

Advice regular medical checkup Advice regular medical checkup

Family health care plan TYPE OF CARE

Medical

FAMILY MEMBER

Ryana Soriano

PROBLEM

Transient milk intoleranc e Mild PEM

RECOMMENDATIO N

Continue formula feeding Advise on proper feeding

Family health care plan TYPE OF CARE

Medical

FAMILY MEMBER

PROBLEM

Honorio

none

Lydia

none

RECOMMENDATIO N

Advice regular medical checkup Advice regular medical checkup

Family health care plan TYPE OF CARE

Wellnes s

FAMILY MEMBER

Ryan

Criselda

Ryana

PROBLEM

Lack of primary medical care and health care Lack of Primary medical care and health care Lack of primary medical care and health care

RECOMMENDATION

Educate them on the importance of going to the doctor’s for a routine check-up Advice: ■Pap’s smear ■Self-breast exam Complete vaccination needed

Family health care plan TYPE OF CARE

Wellness

FAMILY MEMBER

PROBLEM

Honorio

none

Lydia

none

RECOMMENDATIO N

Advice regular medical check-up ■ DRE, FOBT ■FBS, Lipid profile Advice regular medical check-up ■Pap’s smear ■Mammogram ■Self breast exam

Family health care plan TYPE OF CARE

FAMILY MEMBER

Psychosocia Ryan l Soriano Criselda

Ryana Soriano

PROBLEM

RECOMMENDATION S

Due to distance of work, the father can only spend time with his family on weekends.

Try to get work closer to home or find a suitable place where he can have his family living with him.

Due to distance of husband’s job she is unable to see him or speak with him on a regular basis. She is unhappy due to the fact that she lives with her husband’s family where she feels unwelcome. Due to the distance of father’s work, the child is unable to completely bond with him.

Try and communicate with her husband by letting him know how she feels about their current living situation. Together with her husband, they should let his family members know that they make her feel like an outcast. The father should try to work closer to home or at least try and get home more often.

Family health care plan TYPE OF CARE

Others

FAMILY MEMBER

PROBLEM

RECOMMENDATI ON

Lacks the training of raising her child since she gave birth at such an early age. Lack of financial support from the father. Has a very unstable family unit. Where in the father is separated from the child for a long period of time

Learn parenting skills. Go to support groups that help and teach young women how to raise a child.

Ryan Criselda

Ryana

The end ;)