Community Grand Rounds-print

COMMUNITY GRAND ROUNDS Group 2 Suller, Armida Sunga, Mary Anne Suntay, Ma. Lourdes Sy, Jennifer Paula Tabuena, Gertzie Dara Tacujan, Karina Michaela Tad-y, Mia Marie Talusan, Patrick Jason

CLINICAL ASSESSMENT

Clinical Assessment E.B., 11 month old male Area I, Lot 37, Block 52, Brgy. Sto. Niño, Sapang Palay, San del Monte City, Bulacan

Chief Complaint: Yellowish nasal discharge Informant: Mother Reliability: 85%

History of Present Illness • watery nasal discharge

14 days PTC

• cough productive of whitish sputum • persistence of symptoms + fever (38ºC)

13 days PTC

• Paracetamol 1 mL q6h  lysis of fever • Cough productive of yellowish sputum

10 days PTC

• decrease in appetite

7 days PTC

• A> Viral bronchitis • P> Salbutamol 2 mg/5 mL, 2.5 mL q6h for 7 days; Increase fluid intake  cough improved

Consultation

• yellowish nasal discharge

Review of Systems General survey – active – (-) weight loss Cutaneous – (-) rash – (-) pigmentation HEENT – (-) excessive lacrimation, nasal or aural discharge – (-) epistaxis Cardiovascular – (+) fainting spells Respiratory – (-) difficulty of breathing

Gastrointestinal – (-) vomiting – (-) change in bowel movements – (-) food intolerance Genitourinary – light yellow urine – (-) discharge – (-) edema of the hands and feet Nervous – (-) vomiting – (-) convulsions – (-) weakness or paralysis Musculoskeletal – (-) swelling – (-) limping Hematopoietic – (-) pallor – (-) easy bruisability

Past Personal History Gestational History – 21 y/o – G2P1 (1-1-0-1) – healthy – good nutrition – no infections – no intake of drugs – 9 months gestation

Past Personal History Birth History – term – NSD – physician attended the birth (Ospital ng Maynila – birthweight 7.5 lbs

Past Personal History Neonatal History – spontaneous respiration, no required resuscitation – acyanotic – no pallor or jaundice – no convulsions – no hemorrhage or feeding difficulties

Past Personal History Feeding History – Breastfed for 1 month – Age weaned: 1 month; reason: due to galactocoele – Formula: Bona – Medications: multivitamins – Food intake: (+) solid foods at 6 months – fed every (hours)? – consumes (bottles of milk in 24 hours)?

Past Personal History Growth and Development - Talked: 6 mos (“mama” and “papa”) 11 mos (other than “mama” and “papa”) - Sat alone: 9 mos - Stood alone: 10 mos

Past Personal History Immunizations – BCG (1 mo) – DPT, OPV (2,3,and 4 mos) – Measles (9 mos) • Where was it given? (health center, hospital)?

Past Personal History Past Illnesses – Dx: pneumonia at 8 mos Rx: Cotrimoxazole 200 mg/40 mg/5 mL syrup, given 2.5 mL q12h for 5 days – no operations – no asthma or known drug sensitivities – no injuries

Family History

• Parents: – Father: Jojo, 25 y/o, no permanent occupation, healthy – Mother: Adeline, 22 y/o, housewife, healthy

• Siblings: – Older brother died at 2 days old • Familial illness or anomalies: – (+) Cardiovascular disease - grandmother – (-) Tuberculosis, diabetes mellitus, syphilis, cancer, epilepsy, rheumatic fever, allergy, hereditary hematological disorders, mental retardation, congenital defects, etc.

Socioeconomic and Environmental History Living Circumstances – Two-storey house, made of concrete, space enough for six people, well-ventilated.

Economic – Family’s source of income: father (construction worker in Manila)

Environmental – (+) exposure to cigarette smoke (mother)

Physical Examination General: conscious, not in distress, well malnourished, good hydration, and well-developed Vital signs and Anthropometrics: – Height: 77 cm (p75) – Weight: 10 kg (p50) – HC: 47 cm (p75) – CC: 48 cm – AC: 45 cm – RR: 35 bpm – PR: 116 bpm – T: 36oC

Physical Examination • WFA: actual wt/wt at p50 x 100 = (10kg/10 kg) x 100 = 100 %  normal • HFA: actual ht/ ht at p50 x 100 = (77 cm/ 74 cm) x 100 = 104 %  normal • WFH: actual wt/ wt at ht p50 x 100 = (10 kg/10.6 g) x 100 = 94.33 %  normal

Physical Examination Skin – fair, good turgor, no rashes, no scars, no edema

Head – equal distribution of hair, normocephalic and atraumatic, anterior and posterior fontanels are closed, no abnormal swelling or depressions, no overlapping sutures

Eyes – pink palpebral conjunctiva, anicteric sclerae, pupils ERTL, no opacities or abnormal discharge

Physical Examination Ears – no abnormal discharge, no inflammation or foreign bodies Nose – patent nares, no flaring of alar nasi, midline septum Oral Cavity – pink, moist buccal mucosa, (+) upper and lower central incisors, no lesion or hemorrhages, non-hyperemic posterior pharyngeal walls, tonsils not enlarged

Physical Examination Neck – no venous engorgement, no rigidity, no thyroid enlargement, no abnormal masses, no palpable lymph nodes

Thorax – symmetric chest expansion, no retractions, head circumference > chest circumference

Lungs – no lagging, clear breath sounds

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

Abdomen – globular, umbilicus midline, no visible veins or abnormal pulsations, normoactive bowel sounds, nontender, no masses, tympanitic

Physical Examination Extremities – pulses regular, full and equal

Neurologic Examination – General: alert, normal facial movements – Motor: symmetry of arm and leg movements, normal muscle bulk, no atrophy, adequate muscle strength for age, good grasp of objects – Cerebellar: no tremors and not hypotonic – Developmental reflexes: (+) palmar and plantar grasp reflex, (-) Moro, rooting and tonic neck reflex – Primitive postural reflexes: (-) placing and stepping reflex, (+) supporting reaction, (+) Landau reflex

DIFFERENTIAL DIAGNOSES

ACUTE BRONCHITIS • inflammation of the trachea, bronchi, and bronchioles • 90% are viral in origin • Prevalent throughout the world • One of the top 5 reasons for childhood physician visits • Peak age: <2 years; 9-15 years old

ACUTE BRONCHITIS • Cough, watery nasal discharge, fever, sore throat • Crackles, rhonchi or wheezing • Self-limited (Resolves in 10-14 days) – Supportive (hydration, oxygen, antipyretics, avoidance of smoke) – Bronchodilators, antitussives, expectorant

BRONCHIOLITIS • Acute infectious disease of the lower respiratory tract • Primarily in young infants, most often in those aged 2-24 months. • Due to a viral infection of the small airways (bronchioles) • MOST COMMON pathogen: RSV

BRONCHIOLITIS • MOST COMMON PHYSICAL SIGN: tachypnea • Other signs and symptoms: cough, lowgrade fever, rhinorrhea, wheezing, signs of respiratory distress • Treatment: Supportive

PHARYNGITIS • An inflammatory process of the oropharynx, primarily caused by infections • Streptococcal pharyngitis can affect persons of all ages, • Peak incidence in children: 5-15 years • Unusual in children younger than 2 years • Low-grade fever, clear rhinitis, irritability, and anorexia • Erythema & inflammation of uvula and pharynx • Treatment: Penicillin for 10 days

Impression Upper Respiratory Tract Infection t/c Acute Bronchitis

discussion • Spectrum of URIs - rhinitis - rhinosinusitis – “common cold” - nasopharyngitis - pharyngitis - laryngitis - laryngotracheatis - tracheatis

discussion Rhinosinusitis defined “A group of disorders characterized by inflammation of the nasal mucosa and paranasal sinuses”

discussion • Pathogenesis of URI physical Direct inhalation

Invasion of mucosa

Interaction w/ Immune defenses

Hand to mouth/nose Incubation of pathogen

Production of symptoms

humoral

cellular

discussion Predisposing Factors: –Viral URI – Allergic Rhinitis –GERD – Immunologic Defects – Ciliary dysfunction – Cystic Fibrosis

Ostia Patency

Mucociliary Clearance Quality of Secretion

discussion -Viral URI Inflammation of the sinus ostia Stasis /poor ventilation Absorption of O2 Negative pressure Movement of bacteria and nasal contents into the sinus

discussion • Signs and symptoms of common colds • • • • • •

Sore or “scratchy throat” Nasal obstruction Rhinorrhea Cough Fever – influenza, RSV, adenovirus Swollen, erythematous nasal turbinates

Discussion incidence • school children may suffer 7 to 10 colds/yr • 0.5% to 2% of viral URTIs are complicated by bacterial infection • 13,517 out-patient consults seen from Jan. to June 2005 – ABRS consists of 140 cases (1.035%) – 36% of all cases consulting for rhinitis

Discussion Other risk factors for URIs – Group settings and crowded places – Travel – Smoking and exposure to second-hand smoke – Immunocompromise – Anatomic changes – Carrier state

Discussion ACUTE BRONCHITIS Infectious agent Tracheobronchial epithelium Activation of inflammatory cells & release of cytokines

Discussion • Symptoms – Fever – Malaise – Rhinitis – Frequent dry hacking cough - 3-4 days after – Purulent sputum

Discussion • Physical Examination: – Absent or low grade fever – Upper respiratory signs – Coarse breath sounds – Coarse and fine crackles – Scattered high pitched wheezing

Treatment • No real treatment for rhinosinusitis – Caused by rhinovirus (101 sero types)

• Symptomatic treatment – Fluids, proper nutrition – Fever: antipyretic (Paracetamol) – Nasal Obstruction: nasal decongestants (Xylometazoline HCl) – Rhinorrhea: Antihistamines (Loratidine), Ipratropium bromide – Sore Throat: mild analgesics (acetaminophen) – Cough: Antihistamines (Loratidine)

Treatment • Acute viral bronchitis – No real treatment – Self- limited – Shifts in position: facilitate pulmonary drainage – Bronchodilators: Salbutamol

Treatment • cool mist vaporizer or humidifier – help decrease bronchial irritation

• Cough suppressant – dextromethorphan – Risk suppuration and insipissated secretions

• Guaifenesin – loosen secretions

FAMILY ASSESSMENT

FAMILY GENOGRAM Rodolfo

Bong,29 Jennifer,27

Allyna,6mos

Lorena

Carlo,25

Charles

Rinna,15

Jonathan,27 Charlene,26

Natalene,6

Nathaniel,1yr &8mos

Eugene Carl,11mos

Arlene

Adeline,22

FAMILY PROFILE FAMILY MEMBER

AGE/SEX

CIVIL STATUS

RELATIONSHIP TO THE HEAD OF THE FAMILY

EDUCATIONAL ATTAINMENT

OCCUPATION

STAYING WITH THE FAMILY?

Rodolfo Asentista

48/M

M

Breadwinner

High School Graduate

Caddy

Yes

Lorena Asentista

45/F

M

Partner of Rodolfo

High School Graduate

Housewife

Yes

Rinna Asentista

15/F

S

Daughter of Rodolfo and Tess

College Student

-

Yes

Allyna Marithea Abella

6 mos/F

S

Daughter of Jennifer and Bong

-

-

Yes

Carlo Asentista

25/M

M

Son of Rodolfo and Lorena

High School Graduate

Waiter

Yes

Adeline Balanay

22/F

M

Daughter-in-law of Rodolfo and Lorena

High School Graduate

Housewife

Yes

Eugene Carl Asentista

11 mos/M

S

Grandson of Rodolfo and Lorena

-

Yes

-

FAMILY LIFELINE • 2005 - Carlo and Adeline lived-in • 2006 - Eugene Carl was born - Eugene had pneumonia

FAMILY LIFE CYCLE FAMILY WITH YOUNG CHILD First Order Changes • Meeting predictable and unexpected costs of family life with a small child • Sharing responsibilities • Maintaining mutually satisfactory sexual relationship and planning for future children • Facing dilemmas and reworking philosophies • Assuring a healthy environment for the child

FAMILY LIFE CYCLE Second Order Changes • Realignment of relationship with extended family to include parenting and grandparenting roles • Creating and maintaining effective communication system • Cultivating full potentials of relationship with relatives within the extended family • Tapping resources, serving needs and enjoying contracts outside the family

PROBLEMS ENCOUNTERED Medical • Eugene’s Upper Respiratory Tract Infection • Smoking habits of both Carlo and Adeline

PROBLEMS ENCOUNTERED Emotional and Social • Financial difficulties – Carlo is not earning enough for his family • “Not so good” relationship of Adeline with her mother-in-law • Frequent disagreements between Carlo and Adeline

ECONOMIC PROFILE

MONTHLY ALLOCATION OF INCOME • • • • • • • • • •

Food 6% Electricity 50% Shelter 4% Household items 5% Water 20% Health 8% Recreation 1.5% Clothing 2% Savings 3% Others 0.5%

Monthly Allocation of Income Food Electricity 3%1% 6% 8% 2%2%

Shelter Household items Water Health

20% 49% 5% 4%

Recreation Clothing Savings Others

ECONOMIC PROFILE EARNING FAMILY MEMBER

OCCUPATION INCOME PER MONTH

OTHER SOURCES OF INCOME

Rodolfo Asentista

Caddy

P10,000

Pigs (P1200 per pig)

Carlo Asentista

Waiter

P2,000

-

LOCATION MAP

General Floor Plan:

Stairs

Living Room

And Dining Area

Windows

Kitchen

Bedroom

Bathroom

Bed

Attic

ENVIRONMENTAL PROFILE House Two storey, owned by grandfather Type Mixed (concrete, wood and GI sheets) Number of bedrooms 2 bedrooms, kitchen, living room, 1 bath and toilet Order and cleanliness Minimal clutter Floor area Living room doubles as sleeping quarters Flooring Tiles and wood Ventilation 4 windows Electric supply Meralco Lighting Good Lighting facilities Fluorescent lights

ENVIRONMENTAL PROFILE Water Drinking water Toilet type Refuse disposal Garbage collection Drainage

NAWASA (local water district) Tap water Manual flush (buhos-type) Not segregated Disposable diapers only every Mondays Incineration Open

Vermin/insects

Mosquitoes, mice, cockroaches, no vermin control used Pets: 5 dogs, 12 puppies, 2 pigs and poultry

Neighborhood

Located near a barangay health center, St. Martin, school and public market

Accessibility

Dirt road

ASSESSMENT POSITIVE POINTS

NEGATIVE POINTS

Accessible

Road not cemented (dirt road)

Sufficient and clean water source

Presence of stray dogs and cats

With electrical source

No waste segregation No vermin control

TOOLS OF ASSESSMENT APGAR SCREEM

APGAR: Adeline A

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

1

P

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

2

G

Ako’y nasisiyahan at ang aking pamilya ay tinatanggap 2 at sinusuportahan ang akong nais na gawin patungo sa mga bagong landas para sa aking ikauunlad

A

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

1

R

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

1

TOTAL

7

APGAR: 1.

Sino-sino ang mga nakatira sa inyong tirahan? Ano ang iyong relasyon? - Sa mga manugang kadalasan ay pinanasyal na tulong. a. In the future, what is the family’s primary goal? - Their primary goal is to have all their kids finish school and have a good, stable job. b. Do all the members work together towards these goals/desires? How? If not, what seems to be the hindrance for working together? - Yes, usually by communicating openly to each other.

c. Is there any history of alcoholism, gambling, drug abuse/dependency, domestic violence? Has something been done to address this problem? - Yes, specifically alcohol and drug use. In the past, both Carlo and Adeline used Marijuana and shabu but was not addicted to it. Carlo is an occasional drinker of alcohol. d. To what organization does the family belong to? - El Shaddai

SCREEM: Parameter

Strength

Social

-Open communication -Slightly supportive - No rivalries

Cultural

- Absence of beliefs/practices that are unacceptable in our culture

Religion

- Religion of the family: Roman Catholic -Joined El Shaddai - Strong Relationship with God

Weaknesses

Education -Both parents are High School graduates

Economic

- Good allocation of funds Inspite that sometimes there is lack of money.

Medical

- compliant

-Level of education hinders the progress of the family

- most of the time borrows money from neighbors

COMMUNITY ASSESSMENT

COMMUNITY ASSESSMENT Positive points • There are no piles of garbage in the area. • The community is closely knit. They look after each other’s welfare.

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.