Department of Family and Community Medicine

Brokenshire Integrated Health Ministries Inc.

Madapo Hills, Davao City

Gallera, Alma S.
Monsanto, Melody Kaye A.
Tadlas, Joevet T.

Post Graduate Interns

2017-2018
GENERAL OBJECTIVES

1. To discuss a case of a 46-year old, male who came in in this institution with an abdominal

pain

2. To briefly discuss a general approach in maintaining good control of a medical condition

3. To take into considerations in par with the medical case of patient’s biomedical and

psychosocial impact of the illness as well as of the family’s.

SPECIFIC OBJECTIVES

1. To have a thorough discussion of the biomedical aspect of the index patient’s condition

2. To discuss the patient’s psychosocial aspect at par with his condition

3. To discuss in the analysis of the family’s dynamics using the appropriate assessment tools

4. To discuss the formulated biomedical and psychosocial wellness plans for each of the family

members

5. To discuss the family problems leading to family dysfunction and interventions

MEDICAL SCENARIO
General Data
E.A, a 46-year old, male, married, Filipino, Roman Catholic, PUJ Operator, was born on

April 25, 1971 in Lupon, Davao Oriental currently residing at Blk. 19, Lot 11,Ezekiel St. Emily

Homes, Cabantian, Davao City admitted for the first time in this institution.

Informant
Patient with 100% reliability

Chief Compliant
Abdominal pain
History of Present Illness
4 months prior to admission, patient had sudden onset of intermittent abdominal pain

prominent in the right upper quadrant area stabbing in character, with PS of 5/10, non-radiating,

aggravated upon exertion and movement, associated with nausea and vomiting of saliva, 4x; no

febrile episodes, no dizziness, no dyspnea. Patient sought consult with attending physician,

ultrasound of whole abdomen was initially ordered which revealed acalculous cholecystitis and

tiny polyps; Patient was advised for surgical intervention but did not comply instead opted for

medical management. Patient was given unrecalled pain reliever which gave temporary relief.

Patient tolerated condition.

A week prior to admission, recurrence of pain noted, now with nausea and vomiting of

previously ingested food, 2x, approximate of ½ glass per episode. No other associated signs

and symptoms. No consult done. No medications taken. Patient tolerated condition.

5 hours prior to consult, patient symptoms persisted, condition worsened, right upper

quadrant pain, PS now 10/10, patient cannot tolerate condition, sought consult in this institution

and was subsequently admitted.

Past Medical History

Patient is non diabetic, non-hypertensive, non-asthmatic, no known allergies to foods

and drugs, no previous hospitalizations and no surgical operations, no maintenance

medications.

Family History
Patient’s father is diagnosed of Diabetes Mellitus type II while his mother is diagnosed of

Hypertension stage II. Patient’s grandfather from his mother side was diagnosed with Liver

Cancer, his aunt from his mother side was diagnosed with Breast Cancer and another aunt was
diagnosed with Hypertension. On his father side, his grandmother was diagnosed with

Hypertension.

Personal & Social History

Patient is a graduate of vocational course for 7 months as a caregiver and 6 months in

automotive. He is married for 14 years, and has 1 child whom he is currently living with. He is a

PUJ operator and owns 2 jeepneys. Family’s financial assistance is mostly provided by him, and

is supported with his wife who is a Primary teacher. Patient has no known food and drug

allergies. He is non-smoker and non-alcoholic drinker.

Review of System:
General: No history of weight loss and fatigue. No fever or chills reported.

Eyes: No blurring of vision, no history of glaucoma or cataract.

Ear, Nose, and Throat: No vertigo reported. No frequent sore throat nor is there nosebleed.

Respiratory: No shortness of breath nor persistent cough reported.

Cardiovascular: No chest pain reported.

Gastrointestinal: No constipation. Patient reported abdominal pain on the right upper quadrant

area

Genitourinary: Neither pain nor burning sensation upon urinating. No hematuria reported.

Musculoskeletal: No intermittent weakness of both lower extremities and back pain reported.

Physical Examination
General Survey: Patient is awake, conscious, in pain, not in respiratory distress with the

following vital signs:

BP: 130/90 mm Hg, right arm RR: 24 cpm O2sat 99% Ht: 5’7”

HR: 84 bpm, bounding, regular TEMP: 36.5 ° C Wt: 79 kgs BMI: 27 kg/m2
Skin: warm to touch, good skin turgor and mobility

HEENT: anicteric sclera, pale palpebral conjunctiva, (-) naso-aural discharges, moist oral

mucosa

Chest/Lungs: clear breath sounds, equal chest expansion,

Cardiovascular: adynamic precordium, distinct heart sounds, normal rate, regular rhythm, (-)

murmurs

Abdomen: soft, flabby, (+) direct tenderness on the RUQ, (+) murphy’s sign

GUT: grossly male, (-) KPS

DRE: good sphincter tone, (-) tenderness, (-) mass, (-) blood and fecal material on examining

finger

Extremities: strong peripheral pulse, CRT <2 sec, (-) edema

Neurologic Examination:

Cerebral: alert, awake, coherent, oriented to time, place, and person

Cerebellar: normal gait, smooth and coordinated rapid alternating movements

Cranial Nerves:

I: unable to perform

II, III: (+) pupillary light reflex, direct and consensual in each eye

III, IV, VI: smooth & full range of extra-ocular muscle movement by Finger Following Test

V: (+) corneal reflex, strong & symmetrical muscles of mastication, intact facial sensation

VII: no facial asymmetry, facial expressions symmetrical

 VIII: can hear spoken voice at 2 feet

IX, X: (+) gag reflex, able to swallow without difficulty, uvula at midline at rest and upon

phonation

XI: able to shrug both shoulders against resistance

XII: tongue at midline at rest and on protrusion

Sensory: intact sensation to pain and light touch on upper and lower extremities

Motor: good muscle tone, no tremors, no fasciculations,

Muscle strength:
5/5 5/5
5/5 5/5
Reflexes:

Salient Features:

 46-year old
 Male
 79 kgs
 BMI: 27 kg/m2
 sudden onset of intermittent abdominal pain
 prominent in the right upper quadrant area, PS of 5/10, non-radiating,
 nausea and vomiting
 (+) direct tenderness on the RUQ
 (+) murphy’s sign

Differential Diagnosis:

Appendicitis
 Appendicitis is one of the most common surgical emergencies in contemporary

medicine. Right lower quadrant pain, gastrointestinal symptoms starting after the onset of pain,

and a systemic inflammatory response with leukocytosis and neutrophilia, increased C-reactive

protein concentration, and fever are considered diagnostic of appendicitis.

o Rule In: abdominal pain, nausea and vomiting

o Rule out: prominent in the right upper quadrant area

Acute Gastroenteritis

Acute Gastroenteritis is diarrhea or vomiting, or both, of more than several episodes or

days duration. Most often appear within 4 to 48 hours after contact with the virus. Common

symptoms include: abdominal pain, diarrhea, nausea and vomiting, chills, clammy skin or

sweating, fever, joint stiffening or muscle pain, poor feeding and weight loss.

o Rule in: abdominal pain, nausea and vomiting

o Rule out: cannot totally rule out

Acute Uncomplicated Urinary Tract Infection

Uncomplicated urinary tract infection refers to the invasion of a structurally and

functionally normal urinary tract by a nonresident infectious organism. UTI may be

asymptomatic, patient sometimes report of incontinence, dysuria, fever, suprapubic or lower

abdominal pain and anorexia.

o Rule in: abdominal pain, nausea and vomiting

o Rule out: no dysuria, (-) KPS, no febrile episodes

Cholelithiasis

One of the most common problems affecting the digestive tract. The chief symptom

associated with symptomatic gallstones is pain. The pain is constant and increases in severity
over the first half hour or so and typically lasts 1 to 5 hours. It is located in the epigastrium or

right upper quadrant and frequently radiates to the right upper back or between the scapulae. It

often is associated with nausea and sometimes vomiting

o Rule in: abdominal pain prominent in the RUQ area, nausea and vomiting, (+)
murphy’s sign
o Rule out: cannot totally rule out

Acute Gastroenteritis Cholelithiasis

46 years old  
Male  
79 kgs (BMI: 27 kg/m2)  
sudden onset of intermittent  
abdominal pain
prominent in the right upper  
quadrant area
nausea and vomiting  
(+) direct tenderness on the  
RUQ
(+) murphy’s sign  

Admitting Diagnosis:
Cholelithiasis

Course in the Ward

12/16/17 Upon Admission

Subjective Objective Assessment Plan
Patient complained of - Stable VS Cholelithiasis - Secure consent to care
Right Upper Quadrant - Anicteric sclerae, Pink - NPO temporarily
pain, non-radiating Palpebral Conjunctivae - V/S q4
- Equal chest - I&O q shift
expansion, Clear - IVF: D5LR 1L @ 120 cc/hr
breath sound - Labs:
- Adynamic precordium, 1. CBC 6 hours post vomiting
Distinct heart sounds 2. UA
- (+) direct tenderness 3. USD WA
on the RUQ, (+) 4. S.electrolytes
5. S.crea
murphy’s sign 6. SGPT
- Strong pulses, CRT 7. ECG
<2 seconds - Meds:
1. HNBB 1amp IVTT q8 PRN for
abdominal pain
2. Metoclopramide 1 amp IVTT q8
then PRN for vomiting
- Watch out for persistence of
abdominal pain, vomiting and
other unusalties
- Co- management with Dr,
Puracan
- Surgery Notes
- For S. Alk Phos and S.
Amylase
- Omeprazole 40mg IVTT OD
while on NPO
- Schedule for Lap Chole on
Monday (12/18/17) 1st Case
- Anesthesia: Dr. Banzon
- Ciprofloxacin 500mg tab BID
- May have Low Fat Diet

12/17/17 Hospital Day 1

Subjective Objective Assessment Plan
Patient is awake, - Stable VS Cholelithiasis - Ff up Chest X-ray Official
comfortable - Anicteric sclerae, Pink Result
(-) abdominal pain Palpebral Conjunctivae - Relay results once in
(-) febrile episodes - Equal chest - Continue meds and
expansion, Clear monitoring
breath sound
- Adynamic precordium, - Pre Op Orders
Distinct heart sounds - NPO post midnight
- (+) direct tenderness - V/S en route to OR
on the RUQ, (+) - Gen/Oral Hygiene
murphy’s sign - Shift IVF to D5LR 1L @ 120
- Strong pulses, CRT cc/hr once on NPO
<2 seconds - Midazolam 15mg 1 tab, en
route to OR w/ SOW
- No BRP after giving
Midazolam
- Refer

12/18/17 Hospital Day 2

Subjective Objective Assessment Plan
Patient is asleep - Stable VS Cholelithiasis - Post Op Orders
- Anicteric sclerae, Pink -To PACU x 2hrs then back to
Palpebral Conjunctivae room once stable
- Equal chest - GL once fully awake
expansion, Clear - V/S monitoring q15 mins
breath sound x4hrs, q30mins x 4hrs, qshift
- Adynamic precordium, thereafter
Distinct heart sounds - IVF: D5LR 1L @ 120 cc/hr
murphy’s sign - IVF TF: same x 2 cycles
- Strong pulses, CRT - Meds:
<2 seconds - Cipfrofloxacin 500mg tab BID
- Tramadol 50mg q6 very slow
IVTT x 2 more doses then d/c (1st
dose at 3pm)
- Ketorolac 30mg q8 IVTT x
3doses then d/c (1st dose at
PACU)
- Celecoxib 200mg cap, BID (to
start tom AM)
- Nalbuphine 7mg q4 IVTT PRN
for severe breakthrough pain
- MHBR
- O2 inh. @ 3LPMvia NC @
PACU
- I&O monitoring q shift and
record x 24 hours only
- Keep px warm &
thermoregulated
- Specimen to Histopath for
Biopsy

12/19/17 Hospital Day 3

Subjective Objective Assessment Plan
Patient complained of - Stable VS Chronic - Continue meds and
tolerable post op pain - Anicteric sclerae, Pink Calculous monitoring
Palpebral Conjunctivae Cholecystitis - May have soft diet
- Equal chest - D/C Omeprazole
expansion, Clear - MGH once cleared with
breath sound surgery
- Adynamic precordium, - Home Meds c/o Surgery
Distinct heart sounds Service
- soft abdomen, NABS - Encourage ambulation
- Strong pulses, CRT - Advised: Limit fatty food and
<2 seconds alcoholic beverages

Case Discussion:

ANATOMY
Gallbladder
The gallbladder is a pear-shaped sac, about 7 to 10 cm long, with an average capacity

of 30 to 50 mL. The gallbladder is located in a fossa on the inferior surface of the liver.

The gallbladder is divided into four anatomic areas: the fundus, the corpus (body), the

infundibulum, and the neck. The fundus is the rounded, blind end that normally extends 1 to 2

cm beyond the liver’s margin.

It contains most of the smooth muscles of the organ, in contrast to the body, which is the

main storage area and contains most of the elastic tissue. The body extends from the fundus

and tapers into the neck, a funnel-shaped area that connects with the cystic duct. The neck

usually follows a gentle curve, the convexity of which may be enlarged to form the infundibulum

or Hartmann’s pouch. The neck lies in the deepest part of the gallbladder fossa and extends into

the free portion of the hepatoduodenal ligament.

The cystic artery that supplies the gallbladder is usually a branch of the right hepatic

artery (>90% of the time). The course of the cystic artery may vary, but it nearly always is found
within the hepatocystic triangle, the area bound by the cystic duct, common hepatic duct, and

the liver margin (triangle of Calot).

Venous return is carried either through small veins that enter directly into the liver or,

rarely, to a large cystic vein that carries blood back to the portal vein. Gallbladder lymphatics

drain into nodes at the neck of the gallbladder. Frequently, a visible lymph node overlies the

insertion of the cystic artery into the gallbladder wall. The nerves of the gallbladder arise from

the vagus and from sympathetic branches that pass through the celiac plexus.

Physiology
The liver produces bile continuously and excretes it into the bile canaliculi. The normal

adult consuming an average diet produces within the liver 500 to 1000 mL of bile a day. The

secretion of bile is responsive to neurogenic, humoral, and chemical stimuli.

Hydrochloric acid, partly digested proteins, and fatty acids in the duodenum stimulate the

release of secretin from the duodenum that, in turn, increases bile production and bile flow. Bile

flows from the liver through to the hepatic ducts, into the common hepatic duct, through the

common bile duct, and finally into the duodenum. With an intact sphincter of Oddi, bile flow is

directed into the gallbladder.

Bile is mainly composed of water, electrolytes, bile salts, proteins, lipids, and bile

pigments. Sodium, potassium, calcium, and chlorine have the same concentration in bile as in

plasma or extracellular fluid

Bile salts are excreted into the bile by the hepatocyte and aid in the digestion and

absorption of fats in the intestines.

In the intestines, about 80% of the conjugated bile acids are absorbed in the terminal

ileum. The remainder is dehydroxylated (deconjugated) by gut bacteria, forming secondary bile
acids deoxycholate and lithocholate. These are absorbed in the colon, transported to the liver,

conjugated, and secreted into the bile. Eventually, about 95% of the bile acid pool is reabsorbed

and returned via the portal venous system to the liver, the so-called enterohepatic circulation.

Five percent is excreted in the stool, leaving the relatively small amount of bile acids to have

maximum effect.

Cholesterol and phospholipids synthesized in the liver are the principal lipids found in

bile. The color of the bile is due to the presence of the pigment bilirubin diglucuronide, which is

the metabolic product from the breakdown of hemoglobin and is present in bile in concentrations

100 times greater than in plasma. Once in the intestine, bacteria convert it into urobilinogen, a

small fraction of which is absorbed and secreted into the bile.

Gallbladder Function
The gallbladder, the bile ducts, and the sphincter of Oddi act together to store and

regulate the flow of bile. The main function of the gallbladder is to concentrate and store hepatic

bile and to deliver bile into the duodenum in response to a meal.

Gallstone disease

 One of the most common problems affecting the digestive tract

 The prevalence of gallstones is related to many factors, including age, gender, and

ethnic background
 Obesity, pregnancy, dietary factors, Crohn’s disease, terminal ileal resection, gastric

surgery, hereditary spherocytosis, sickle cell disease, and thalassemia are all

associated with an increased risk of developing gallstones

 Women are three times more likely to develop gallstone

Natural History

 Most patients will remain asymptomatic from their gallstones throughout life
 Some patients progress to a symptomatic stage, with biliary colic caused by a stone

obstructing the cystic duct

  Gallstones in patients without biliary symptoms are commonly diagnosed incidentally on

ultrasonography, CT scans, or abdominal radiography or at laparotomy

Gallstone Formation

Gallstones form as a result of solids settling out of solution. The major organic solutes in bile are

bilirubin, bile salts, phospholipids, and cholesterol.

 Cholesterol Stones
1. Pure cholesterol stones are uncommon and account for <10% of all stones. They

usually occur as single large stones with smooth surfaces.

2. Cholesterol is secreted into bile as cholesterol-phospholipid vesicles.
3. Cholesterol is held in solution by micelles, a conjugated bile salt-phospholipid-

cholesterol complex, as well as by the cholesterol-phospholipid vesicles

4. Vesicular maturation occurs when vesicular lipids are incorporated into micelles
 Pigment Stones
1. Pigment stones contain <20% cholesterol and are dark because of the presence

of calcium bilirubinate
2. Black pigment stones are usually small, brittle, black, and sometimes spiculated.

They are formed by supersaturation of calcium bilirubinate, carbonate, and

phosphate
3. Brown stones are usually <1 cm in diameter, brownishyellow, soft, and often

mushy. They may form either in the gallbladder or in the bile ducts, usually

secondary to bacterial infection caused by bile stasis. Precipitated calcium

bilirubinate and bacterial cell bodies compose the major part of the stone

Symptomatic Gallstones

Chronic Cholecystitis (Biliary Colic)

 Characterized by recurrent attacks of pain, often inaccurately labeled biliary colic. The

pain develops when a stone obstructs the cystic duct, resulting in a progressive increase

of tension in the gallbladder wall.

 The chief symptom associated with symptomatic gallstones is pain.
  The pain is constant and increases in severity over the first half hour or so and typically

lasts 1 to 5 hours. It is located in the epigastrium or right upper quadrant and frequently

radiates to the right upper back or between the scapulae

 It often is associated with nausea and sometimes vomiting.
 Physical examination may reveal mild right upper quadrant tenderness during an

episode of pain. If the patient is pain free, the physical examination is usually

unremarkable. Laboratory values, such as WBC count and liver function tests, are

usually normal in patients with uncomplicated gallstones.

Diagnostic Studies:
Blood tests:

 Complete blood count

 Liver function tests

An elevated white blood cell (WBC) count may indicate or raise suspicion of

cholecystitis. If associated with an elevation of bilirubin, alkaline phosphatase, and

aminotransferase, cholangitis should be suspected. Cholestasis, an obstruction to bile flow, is

characterized by an elevation of bilirubin (i.e., the conjugated form) and a rise in alkaline

phosphatase. Serum aminotransferases may be normal or mildly elevated. In patients with

biliary colic or chronic cholecystitis, blood tests will typically be normal.

Ultrasonography

 An ultrasound is the initial investigation of any patient suspected of disease of the biliary

tree.
 It is noninvasive, painless, does not submit the patient to radiation, and can be

performed on critically ill patients.

 This procedure was done to our patient, and is one of the preferred diagnostics imaging.

Biliary Radionuclide Scanning (HIDA Scan)

  Provides a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum

with both anatomic and functional information.

 The primary use of biliary scintigraphy is in the diagnosis of acute cholecystitis, which

appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and

duodenum.
 However, this procedure was not done to our patients.

Computed Tomography

 Abdominal CT scans are inferior to ultrasonography in diagnosing gallstones.

 The major application of CT scans is to define the course and status of the extrahepatic

biliary tree and adjacent structures.

 It is the test of choice in evaluating the patient with suspected malignancy of the

gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of

the pancreas
 However, this procedure was not done to our patients.

Percutaneous Transhepatic Cholangiography

 Intrahepatic bile ducts are accessed percutaneously with a small needle under

fluoroscopic guidance.
 Has little role in the management of patients with uncomplicated gallstone disease but is

particularly useful in patients with bile duct strictures and tumors, as it defines the

anatomy of the biliary tree proximal to the affected segment

 However, this procedure was not done to our patients.

Magnetic Resonance Imaging

 MRI provides anatomic details of the liver, gallbladder, and pancreas similar to those

obtained from CT
 It has a sensitivity and specificity of 95% and 89%, respectively, at detecting

choledocholithiasis
 However, this procedure was not done to our patients.

Endoscopic Retrograde Cholangiopancreatography

 The procedure requires intravenous (IV) sedation for the patient

  The advantages of ERC include direct visualization of the ampullary region and direct

access to the distal common bile duct, with the possibility of therapeutic intervention
 ERC is the diagnostic and often therapeutic procedure of choice
 However, this procedure was not done to our patients.

Endoscopic Ultrasound

 Endoscopic ultrasound requires a special endoscope with an ultrasound transducer at its

tip
 The results are operator dependent, but offer noninvasive imaging of the bile ducts and

adjacent structure
 However, this procedure was not done to our patients.

Management

 Patients with symptomatic gallstones should be advised to have elective laparoscopic

cholecystectomy.
 Advised to avoid dietary fats and large meals.
 Diabetic patients with symptomatic gallstones should have a cholecystectomy promptly,

as they are more prone to develop acute cholecystitis that is often severe.
 Pregnant women with symptomatic gallstones who cannot be managed expectantly with

diet modifications can safely undergo laparoscopic cholecystectomy during the second

trimester.
 Cholecystectomy, open or laparoscopic, for patients with symptomatic gallstones offers

excellent long-term results.

.
FAMILY PROFILE

Name Age Educational Attainment Occupation

AA 46 Automotive PUJ operator
BA 45 College graduate/ BSEd Primary Teacher
CA 12 Grade 6 Student

Abrea’s family has 3 family members. BA, is the wife of the index patient. She is 36

years old. She graduated with Bachelor of Science in Education and works as a Primary

Teacher in a public school. CA is the only son of the Abrea family. He is currently a Grade 12

student. He has been excelling academically in which the family states that he is studying hard

to become a doctor someday. AA is the index patient, 46 years old and has graduated a

caregiver course for 7 months. He has also graduated a 2 year course as an automotive.

Currently, he is working as a PUJ operator and works 8 hours per day. He is the major caretaker

of their son and devotedly given utmost attention in caregiving.

FAMILY STRUCTURE

Abrea’s family is a nuclear type of family. The married couple lives with their son under

one roof. No other family members lives with them.

FAMILY ECONOMIC STATUS

 Abrea’s family belong to a middle-class earner. AA is earning approximately 30, 000 per

monthly from his PUJ’s. Her wife, BA is earning 23, 000 monthly. AA and BA has been very keen

in budgeting their income because both provide and divide expenses in their household. Their

partnership can be considered as a dual-earner relationship and both of them consider

themselves as breadwinners. Expenses are allocated in the beginning of the month in house

bills – electricity and water bills, groceries, school fees and allowances, medical fund and the

remaining are kept as savings. AA verbalized that money was never a start of the argument of

the married couple.

AA is the decision maker but still ask advices from his wife, BA. He would make sure that

his wife’s opinions and suggestions are taken into consideration.

AA is the primary caregiver of CA, knowing that he has more knowledge in caregiving

because he has graduated caregiving as a course. He also verbalized that his wife is a bit busy

at school and his is more flexible in taking care of their son.

FAMILY ENVIRONMENT

The family is residing in a secured subdivision wherein the family has already owned the

house several years ago. The house is a duplex type with 1 floor.

There is a comfortable receiving area which was also serves as the entertainment area

of the family. There is 1 bedroom in which the family share. They would sleep together in a

queen-sized bed. They have one clean bathroom. At the back portion of their house a small

backyard which serves as their laundry area.

 Their drinking water is mineral water delivered by a nearby refilling station but what they

are using in bathing and in washing is the water in the faucet provided by Davao City Water

District (DCWD).

Their house is located in Blk. 19, Lot 11, Ezekiel St. Emily Homes, Cabantian, Davao

City.

FAMILY LIFE CYCLE

The family belongs to the Stage III of the Six-Stage Cycle. The family with young

children. The couple with young children face the challenge of taking on the roles of mother and

father as well as husband and wife and of enlarging the family system to include other people.

Thus, the main tasks are realigning the family system to make space for the children, adopting

and developing parenting roles; realigning relationships with families of origin to include

parenting and grandparenting roles and encouraging children to develop peer relationships.

FAMILY TRAJECTORY

Stage I. Onset of Symptoms/Illness

AA had sudden onset of intermittent abdominal pain prominent in the right upper

quadrant area stabbing in character, with PS of 5/10, non-radiating, aggravated upon exertion

and movement, associated with nausea and vomiting of saliva, 4x; no febrile episodes, no

dizziness, no dyspnea. Patient sought consult with attending physician, ultrasound of whole

abdomen was initially ordered which revealed acalculous cholecystitis and tiny polyps; Patient

was advised for surgical intervention but did not comply instead opted for medical management.
Patient was given unrecalled pain reliever which gave temporary relief. Patient tolerated

condition.

A week prior to his admission, AA had recurrence of pain, now with nausea and vomiting

of previously ingested food, 2x, approximate of ½ glass per episode. No other associated signs

and symptoms. No consult done. No medications taken. Patient tolerated condition.

Symptoms persisted, condition worsened, right upper quadrant pain, PS now 10/10,

patient cannot tolerate condition, sought consult in this institution and was subsequently

admitted.

Stage II. Impact Phase – Reaction to Diagnosis

AA was in denial of his condition insisting that his symptoms of right upper quadrant pain

might be gone with compliance in taking of his pain relievers in spite of strong encouragement

of his attending physician for surgical intervention. He verbalized that he was scared of losing

his gallbladder and he sees it a disability knowing of effects of not having a gallbladder. He was

also hesitant due to expensive hospital bills if might be subjected to surgical interventions. He

verbalized that there was a little bit of adjustments of allocations in expenses because they were

able to keep enough savings. He was more concerned on shifting of household roles noting that

he has been the caregiver of their son and his wife has a busy schedule in her school as a

primary teacher,

Stage III. Major Therapeutic Efforts

Medical concerns include RUQ pain was advised for surgery by his AP but patient opted

for medical management. Patient was aware of his condition and when his condition persisted.

He then opted to undergo with the surgery, he was referred for co-management with Dr.

Puracan. He has accepted his diagnosis.

Stage IV. Adjustment to Permanency of Outcomes

He said that they were able to cope with the situation with the help of AA’s mother.

Because his mother is the one who takes care of him in the hospital while his wife is taking care

of their child at home. Patient was discharged and advised to continue medications and lifestyle

modifications.

FAMILY GENOGRAM

I
DA ? JM 65 KM 79
FA 78
II
GA HA
75 73
LM 75 MM 71 IA 70 NM 68 OM 51

₱ ₱
AA 46 BA 45 TB ? VC ?
RA 45 SA 45 PB 39 QC 37

DB 17 EB 10 FC 7 GC 1
CA 12 AAA BAA 8 CAA 5
12

Abrea- Ramos Genogram

Informant: Edgar Abrea
Date: 12/19/17

Legend
Diabetes Mellitus Primary Caregiver

Hypertension ₱ Provider

Breast Ca Index Patient

Liver Ca
 For the Family Genogram, DA, the grandfather of AA died during a war. FA, the

grandmother of AA was a known diabetic. They had two children of whom is GA with no

comorbidities and HA, the father of AA who is a known diabetic.

JM, the grandfather of AA from his mother side, died from Liver Cancer, they forgot the

age when he died. KM, the grandmother of AA has no known comorbidities. They had 5

children, 1 son and 4 daughters. IA, the mother of AA is a known hypertensive. NM who is the

4th child of JM and KM was diagnosed with Breast CA and is now in remission.

HA and IA had 4 children, 2 sons and 2 daughters. AA who is the eldest, is our index

patient, provider and he is also the primary caregiver to his son CA who is 12 years old. AA is

married to BA who is a known hypertensive and also one of the provider for the family.

FAMILY MAP

BA CA

GA AA IA

RA PB QC

For the family map, AA has good relationship with his wife, BA represented by the two

parallel solid lines. He stated that he can talk to his wife and share decision making for their

family. Even if they have different decisions sometimes but they always make a compromise to

have a harmonious living.

 AA also has good relationship with his son CA represented by the two parallel solid lines.

Since he is the primary caregiver of his son and CA can easily share his thoughts and CA has

also a good relationship with his mother BA, which can be seen by the two parallel solid lines.

AA has established a good relationship with his parents GA and IA, he can share

anything with his parents. AA also is very close with his siblings RA, PB, and QC despite of

living far away from them.

PARENTING STYLE

AA and BA’s parenting style to their only son can be categorized as a democratic

parenting. CA, their child is given choices and is held responsible for those choices. They said

that they put consequences that are both acceptable and appropriate, but never the ones that

cause harm. They would set up clear rules and expectations while having an open discussion

that would allow listening to their son’s preferences.

They verbalized that this would allow his child to learn by not insisting but through

listening, understanding and experience. This would also prepare him to take up his

responsibilities and lead his life independently in the future.

FAMILY LIFELINE

FAMILY APGAR

APGAR AA BA CA
A I am satisfied that I can turn my family for help when something is troubling 2 2 2
me
P I am satisfied with the way my family talks on things with me & shares 2 2 2
 problems with me
G I am satisfied that my family accepts & supports my wishes to take on new 2 2 2
activities or directions
A I am satisfied with the way my family expresses affection and responds to 2 2 2
my emotions such as anger, sorrow and love
R I am satisfied with the way my family and I share time together 2 2 2
TOTAL 10 10 10

SCREEM

PARAMETER STRENGTH WEAKNESS

Abrea’s family enjoys an open
communication among family members. CA has few friends within the
They have good social interaction among subdivision compare to his
their neighborhood. school.
SOCIAL AA’s family is also within the vicinity of their
subdivision ih which they could easily ask for They are unable to visit their
help. relatives who are staying far
CA has good interaction with his friends at from their place.
school.
There is no evident sense of cultural
CULTURAL None
inferiority in the Abrea’s family.
Abrea family is a Roman Catholic; they go to
church as a family. Abrea family would only visit
the church when they have
RELIGIOUS
They encourage the children to attend time to visit; they can’t visit
Sunday bible class in the nearby church as every Sunday.
often as they can.
The conbined income of the couple are
The family needs addidtional
enough for their expenses and able to susain
savings if the need of
ECONOMIC their daily necessities.
financial assistance arises.
They have savings for emergency cases.
Abrea family members’ educational
background and attainment is enough for
EDUCATIONAL None
them to understand and come up with
solutions to any problems within the family.
MEDICAL Abrea family verbalized that a nearby clinic is Nearest hospital is a bit far
easily accesible when medical assistance is from their vicinity.
 needed. A nearby pharmacy is not
fully equipped with medical
The parents are members of the PHIC. supplies when needed

In the SCREEM questionnaire, the strengths of Abrea Family in Social aspects are; they

enjoys an open communication among family members, they have good social interaction

among their neighborhood, AA’s family is also within the vicinity of their subdivision ih which they

could easily ask for help, CA has good interaction with his friends at school. For the

weaknesses: CA has few friends within the subdivision compare to his school. They are unable

to visit their relatives who are staying far from their place.

For the cultural aspect, the strenght is there is no evident sense of cultural inferiority in

the Abrea’s family.

For the religious aspect, the strenghts are: Abrea family is a Roman Catholic; they go to

church as a family. They encourage the children to attend Sunday bible class in the nearby

church as often as they can. For the weaknesses: Abrea family would only visit the church when

they have time to visit; they can’t visit every Sunday.

For the economic aspect, the strenghts are: The conbined income of the couple are

enough for their expenses and able to susain their daily necessities. They have savings for

emergency cases. For the weaknesses: The family needs addidtional savings if the need of

financial assistance arises.

For the educational aspect, the strenghts are: Abrea family members’ educational

background and attainment is enough for them to understand and come up with solutions to any

problems within the family.

For the medical aspect, the strenghts ae: Abrea family verbalized that a nearby clinic is

easily accesible when medical assistance is needed. The parents are members of the PHIC.
The weaknesses are: Nearest hospital is a bit far from their vicinity. A nearby pharmacy is not

fully equipped with medical supplies when needed.

FAMILY ECOMAP

EDUCATION SOCIAL

ABREA
FAMILY

Abrea family has a strong connection with education. They see that education will
WORK MEDICAL
provide them future resources and equipped their child for his future. They can see that their

child is good at school and it strives them to work hard for him. The family has strong

connection with work. AA is committed to his work as a PUJ operator; he works 8 hours per day.

BA, his wife has a hectic schedule working as a primary teacher at a public school. Socially, the

family has a strong connection. They have good social interaction with their family and

neighborhood. The family has a strong connection with medical. They have easy access to the

nearby clinic and sees to it that they are referred to nearby hospital when the medical case

cannot be handled well.

FAMILY DIAGNOSIS

Nuclear, Middle Income Household, Double Earner, Family with Adolescent, Democratic, Early

Adjustment to Outcome, Moderately Dysfunctional Family Probably Secondary To Sibling

Rivalry and Disengagement???????

FAMILY WELLNESS PLAN

History Screening Immunization Counseling

AA
(index
patient)

PSYCHOSOCIAL PROBLEMS AND INTERVENTIONS

The anxiety of AA rises when surgical intervention was offered. He was scared of the effects

post surgically knowing of the effects of not having gallballder, seeing it as a disability; not

having a complete anatomy. That’s why he opted medical intervention thinking that he could be

possibly be healed.

He was not worried financially because he knows that he has his family and friends that could

help them when financial problem arises.

Subsequently, his anxiety decreases post surgically because his symptoms died down – pain

free. He was a bit worried because he knows that he needs lifestyle modification especially on

his diet, a low fat diet.

For the present problems:

Problem #1 Caregiver???

REPEAT FAMILY APGAR

REPEAT APGAR ON FEB 2017

A I am satisfied that I can turn my family for help when
something is troubling me
P I am satisfied with the way my family talks on things
with me & shares problems with me
G I am satisfied that my family accepts & supports my
wishes to take on new activities or directions
A I am satisfied with the way my family expresses
affection and responds to my emotions such as
anger, sorrow and love
R I am satisfied with the way my family and I share
time together

FUTURE PLANS FOR THE FAMILY

Overall, our future plans for the family are as follows:

1. Work on shifting schedule in taking care of their child

2. A annual wellness clinic visit will be conducted for all the family members

INSIGHTS