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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
2 weeks PTC Change in milk formula

2 days PTC 4 episodes of watery stools


No fever, hematochezia,
tenesmus, vomiting, anorexia
and weight loss

Consultation
ROS
■ Skin ■ Respiratory:
– (-)Rashes – (-) difficulty of breathing
– (-)Color changes – (-) cough
– (-)Pigmentation ■ Urinary
■ HEENT – (-) frequency
– (-)Colds ■ Nervous:
– (-)Ear discharge – (-) vomiting
■ Neck – (-) convulsions
– (-) masses – (-) weakness or paralysis
■ Cardiovascular
■ Hematopoietic:
– (-) pallor
– (-) cyanosis
– (-) 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
■ 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 NON-INFECTIOUS

- Bacterial - Anatomic
- Viral - Malabsorption
- Parasitic - 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 Henry Lilibeth Joseph Ryan Criselda Raymart


21 29 27 Sitangco 24 17 16

Legends:
- Index Patient
Josea Elisa Riyana - Diarrhea
9 months 6
months - Asthma

- Bad relationship
- good relationship
- very good relationship
Map

San Martin de
Porres Socio-
Medical
Center
Family Profile
Name Age Sex Civil Relation to head Educational Staying
status of family attainment with
family?

Ryan 24 M Single Breadwinner HS Yes

Criselda 17 F Single Partner HS Yes

Ryana 6 F Single Daughter - Yes


mos

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 parents-
in-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% 5%
Pampers

15% Milk and


■ Gamot at Cerelac
Gamot &
kalusugan 15 % 50%
Kalusugan
Atbp
■ Others 5% 30%
– Water 2.5%
– Rice 2.5%
■ Damit 0%
■ Ipon 0%
Monthly Allocation of
Honorio’s Income
■ Pagkain 70%
■ Kuryente 20 %
■ Tubig 10% 15%
Pagkain
■ Damit 0% Kuryente
30% Tubig
■ Ipon 0% 50%
Economic Profile:
Sources of Income
Name Occupation Monthly Income Other Sources of
Income

Honorio Driver P10,000 /month -

Ryan Assistant P 2800/month -


cook

Total P 12,800/month
FLOOR PLAN
window window

SALA BED
entertainment
door
center

door
LAUNDRY

KITCHEN Washing
Machine
BATHROOM
BED
Ref
TABLE
Divider
Environmental Profile
Dwelling Unit 1 house, bungalow type;
owned by grandmother
Type Concrete and wood
No of Bedrooms 2
Appliances TV, VHS, radio, electric fan,
refrigerator, electric flat iron,
washing machine
Cleanliness/Order Moderately clean
Ventilation Poorly ventilated

Lighting Fluorescent bulbs


Water Tap water
Environmental Profile
Drinking Water Commercial purified water for
Ryana, tap water
Toilet “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

Ako’y nasisiyahan dahil nakakaasa ako ng tulong sa aking 1 1


A pamilya sa oras ng problema
Ako’y nasisiyahan sa paraang nakikipagtalakayan sa akin 2 2
P ang aking pamilya tungkol sa aking problema
Ako’y nasisiyahan at ang aking pamilya ay tinatanggap at 1 1
G sinusupotahan ang akong nais na gawin patungo sa mga
bagong landas para sa aking ikauunlad
Ako’y nasisiyahan sa paraang ipinadadama ng aking pamilya 0 0
A ng aking pamilya ang kanilang pagmemehal at nauunawaan
ang aking damdamin katulad ng galit, lungkot, at pag-ibig
Ako’y nasisiyahan dahil ang aking pamilya at ako ay 1 1
R nagkakaroon ng panahon para sa isa’t isa
Total 5 5
APGAR
1.Sinu-sino ang mga nakatira sa inyong tirahan? Ano ang inyong relasyon?

Pangalan Relasyon Kasarian Mabuti Di gaanong Di mabuti


mabuti

Ryan Asawa Lalaki

Criselda Asawa Babae

Ryana Anak Babae

Honorio Biyenan Lalaki

Lydia Biyenan Babae


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 Strength Weaknesses
Social -Good relationship with -Poor communication with
neighbors family (in-laws)
-Absence of rivals -Husband is away from
family for 5 days
Cultural - Absence of
beliefs/practices that
are unacceptable in our
culture
Religion - Religion of the
family:
El Shaddai
SCREEM
Education - Both parents literate - Both parents only finished
till high school

Economic - Regular source of - Income is not enough to


income support the family

Medical -Everybody except - The rest of the family does


Ryana are apparently not have regular medical
healthy check-ups
-Ryana has check-ups
regularly
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 of drinking water ■Boiling of the water

■Improper segregation and ■ Educate on proper waste


incineration of waste management
■Teach on how to recycle and make

■Lots of mosquitoes in the area compost


■Cover stagnant water
■ Mosquito net, insect repellant
■Steep, uncemented road ■Caution

■Muddy area especially during ■Caution


rainy season
■Many stray dogs ■Rabies vaccination
■Use of open drainage system ■cover drainage, practice good
hygiene
Family health care plan
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATIO
MEMBER N

Medical Ryan none Advice regular


medical check-
Criselda none up
Advice regular
medical check-
up
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATIO
MEMBER N

Medical Ryana Transient Continue


Soriano milk formula
intoleranc feeding
e
Mild PEM Advise on
proper
feeding
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATIO
MEMBER N

Medical Honorio none Advice regular


medical check-
Lydia none up
Advice regular
medical check-
up
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATION
MEMBER

Ryan Lack of Educate them on the


Wellnes primary importance of going to
s medical care the doctor’s for a routine
and health check-up
care
Criselda Lack of Advice:
Primary ■Pap’s smear
medical care
■Self-breast exam
and health
care
Ryana Lack of Complete vaccination
primary needed
medical care
and health
care
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATIO
MEMBER N

Wellness Honorio none Advice regular


medical check-up
■ DRE, FOBT
■FBS, Lipid profile

Lydia none Advice regular


medical check-up
■Pap’s smear
■Mammogram
■Self breast exam
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATION
MEMBER S

Due to distance of Try to get work closer to


Psychosocia Ryan work, the father can home or find a suitable
only spend time with place where he can have
l Soriano his family on his family living with
weekends. him.

Due to distance of Try and communicate


Criselda husband’s job she is with her husband by
unable to see him or letting him know how
speak with him on a she feels about their
regular basis. current living situation.
She is unhappy due
to the fact that she Together with her
lives with her husband, they should let
husband’s family his family members
where she feels know that they make her
unwelcome. feel like an outcast.
Due to the distance The father should try to
Ryana of father’s work, the work closer to home or
child is unable to at least try and get
Soriano completely bond home more often.
with him.
Family health care plan
TYPE OF CARE FAMILY PROBLEM RECOMMENDATI
MEMBER ON

Others Ryan

Lacks the training of Learn parenting skills.


Criselda raising her child Go to support groups
since she gave birth that help and teach
at such an early young women how to
age. raise a child.
Lack of financial
support from the
father.
Has a very unstable
Ryana family unit. Where in
the father is
separated from the
child for a long
period of time
The end ;)

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