OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
FAMILY CASE ANALYSIS
Patients Name:
LAMBERTO AUSTRIA
Date of Visit:
May 15, 2014
Age/Sex:
60/M
Time of Visit:
10:00 AM
Address:
633 Basco St., Intramuros Manila
Initial Impression:
Mixed Wound Infection, distal area, left leg
Diabetes mellitus Type 2, uncontrolled
Resident-in-Charge:
Dr. Janice Paras
Medical Interns-in-Charge:
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
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.
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:
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.
Peripheral vascular: No reports of leg cramps, edema or varicose
veins.
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, well-defined, 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 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
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.
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 (+) 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
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
Genoveva
56/F
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, OD
Advised consultation to an ophthalmologist for evaluation and
management of cataract
Well advised
Ryan
33/M
Not seen at the time of interview
Raymark
19/M
Not seen at the time of interview
Marjean
11/F
Not seen at the time of interview
Family Wellness Plan:
PRIMARY PREVENTION
SECONDARY PREVENTION
TERTIARY 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
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
DM diet
For FBS every 2-4 weeks until blood sugar is controlled; for
HbA1c every 3-6 months
Triamcinolone cream BID to affected area
Cetirizine 10 mg BID for 5 days
Metformin 500 mg BID
Refer to Department of Ophthalmology for further evaluation and
comanagement of the blurring of vision
Genoveva, 58/F
Annual Physical Examination
Regular age-appropriate 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
Annual BP monitoring
Annual FBS, Lipid Profile determination
Annual Eye check-up
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
N/A
Ryan, 33/M
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
Advise proper use of OTC medications
Health education: Sanitation issues, consumption of junk food,
accident prevention, sexual issues and health risks
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
N/A
Raymark, 19/M
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
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
N/A
Marjean, 11/F
Dental hygiene and monitoring
Education on proper hygiene: bathing every day, nail care, hand
washing
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
BP monitoring annually
Teach breastself examination at age 9
Hearing acuity 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
How to get there?
Patients Household is found by passing 3 houses
along this street
Mrs. Genoveva Austria
The index patient, Lamberto Sr. with his grandchild, Marjean
With the interviewers
1954
Birth of Lamberto (Index patient)
1973
Lamberto and Genoveva got married, started to live together in
Intramuros, Manila
1974
Birth of Gina, their first born via NSD
1975
1977
Birth of Teresa via NSD
Birth of Ryan via NSD
1979
Birth of Irene via NSD
1980
Birth of Raul ; Lamberto started to open food stall and sari
sari store
1983
Birth of Joana via NSD
1985
Birth of Jennifer via NSD
1986
Birth of Lamberto Jr. via NSD
1988
Birth of Jacqueline via NSD
1991
Gina married Reynaldo and moved to Mindoro
1993
Birth of Rommel via NSD
1995
Birth of their 11th child, Raymark via NSD
1997
Teresa married Orlando and moved to Pangasinan
2011
Jacqueline married Alvin and transferred to Tondo
2012
Lamberto was diagnosed to have DM type 2
2013
Joana married Reynaldo