Family Case Presentation

Abad.Imperial.Javate.Palma.Uy.Valencia

Objectives

• To discuss the family profile of Remocaldo familyo To establish the family diagnosis using family

assessment tools• To present a case of a child with cerebral palsy

o To briefly discuss the etiology, pathophysiology and management of cerebral palsy

The Index Case

Index Case Profile

• A.R.• 10 y/o• Female• Filipino• Born Again Christian• Angono, Rizal

Chief Complaint and HPI

• Hip dislocationosustained 3 yrs PTC while her

mother was stretching her legsoconsulted with a GP

advised othropedic consult: cant afford

ono medications taken

Past Medical History

• Diagnosed case of cerebral palsy with microcephalyo Confirmed at 3 moso Underwent EEG showing “holes in the brain” o Was recommended to have CT Scan but cannot afford ito Quadriplegic

Physical therapy till 5 y/oo Cannot swallow on her own or expectorate phlegmo Meds: phenobarbital, I grain

• Has asthma• Frequently have cough, colds, constipation, and UTI

o Bronchopneumonia at 5 y/o Confined for 1 week in a local hospital

Cerebral Palsy

• also known as congenital cerebral diplegia, static encephalopathy, Little’s disease

• a comprehensive diagnostic term used to designate to a group of nonprogressive disorders resulting from malfunction of the motor centers and pathways of the brain

• occurs while the brain is under development ( at most 5 years old)

• permanent• muscles are not defective

Types of Cerebral Palsy

Spastic Athetoid Ataxia

Characterized by:

Tension in muscles;

presence of stretch or

myotatic reflex, contractures

Involuntary, uncoordinated, uncontrollable movements

Difficulties in coordination and

balance

Damaged area: Cortical motor area; pyramidal

tract;

Extrapyramidal tract; basal

ganglia area

cerebellum

Occurrence: 70% 20% 10%

Types of Cerebral Palsy

• Monoplegia – one limb• Hemiplegia – one leg and corresponding arm• Diplegia – similar parts on both sides of the body;

lower limbs more affected• Paraplegia – lower limbs• Quadriplegia – tetraplegia

- both arms and legs- muscles of trunk, face and mouth

Types of Cerebral Palsy

Additional:

• Hearing loss• Poor sight• Speech defects• Learning disabilities• Visual or Auditory Agnosia

Causes

• Damage can occur during prenatal, natal, and postnatal period• Insufficient oxygen• Premature birth• Infections in the mother such as:

- rubella = German measles- cytomegalovirus = viral infection- toxoplasmosis = parasitic infection• Rh disease- incompatibility between blood of

mother and fetus

Causes

• Severe jaundice – yellowing of skin and whites of the eye because of bilirubin

• Brain infections such as :- encephalitis = inflammation of brain- meningitis = inflammation of the membranes covering the brain and spinal cord• Physical brain injuries• the cause of many individual cases of cerebral palsy is unknown!

Symptoms

• Feeble cry • Difficulty in sucking and swallowing• Listlessness or irritability• Failure to follow normal pattern of motor development

( delayed)

Symptoms

• Apparent preference for one hand before the infant is 12-15 months old

• Persistence of infantile/ primitive reflexes• evidence of mental retardation

Family History

• Hypertension• Asthma• No history of cerebral palsy

Birth History

• 25 y/o mother G1P1(1001)• Full term• NSD, local hospital• Attended by an OB-Gyne• Complications:

o Difficult birth: mother slipped during 9 mos, baby shifted position

o Mother had ecclampsiao Convulsions while giving birth

Nutritional History

• Breastfed until 1 y/0• Cannot ingest solid food

o Mashed vegetables, rice, sometimes meat

Immunization

• Local Health Centero BCG – 1 dose o DPT – 3 dose o OPV – 3 dose o Hep B – 3 doseo Measles – 1 dose

Growth and Development

• Not at par with ageo Cannot moveo Cannot talko Mom claims AR can understand

Physical Examination

• General Surveyo conscious, not in cardio-respiratory distress

• Vital Signs:o HR – 110/min o RR – 22/mino Temp – 37.2o C

Physical Examination

• Skin: no cyanosis, rashes on dependent areas, particularly in the buttocks

• HEENT: normocephalic, pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no nasal discharge, intact tympanic membrane, no tonsillopharyngeal congestion

• Neck: supple, no cervical lymphadenopathy

• Thorax/Lungs: symmetrical chest expansion, no retraction, resonant, clear breath sounds, no rales, no wheezes

Physical Examination

• Cardiovascular: adynamic precordium, apex beat at 5th LICS MCL, tachycardic with regular rhythm, no murmur

• Abdomen: flat, normoactive bowel sounds, no organomegaly, soft,, no mass

• Genitourinary: not done

• Extremities: full and equal pulses, no edema, Motor 0/5 on all extremities, Sensory and cerebellars cannot be tested

Family Assessment Tools

Family Lifeline

AR was born and was later

confirmed to have CP

AR’s mother gave birth to AR’s

youngest sibling

AR’s father decided to work

for five days without going

home

AR’s house was struck by a recent

typhoon

AR’s parents accepted her

condition and tried to give her

everything she needs

The whole family welcomed the

baby and worked harder in order to

provide each other’s needs; 2nd child sometimes

feels jealous

Everyone became accustomed to

seeing the head of the family during weekends only

AR’s family moved to AR’s paternal grandparents’ house and are staying there indefinitely

Family Profile

Family Member Age/ Sex Relation to Patient Occupation

MR 64M Grandfather Unemployed

NR 63F Grandmother Unemployed, Occasional Laundry

Washer

BR 34M Father Parking Attendant

MAR 35F Mother Unemployed

KR 9M Brother Student

JR 1M Brother -

Family Genogram

Family Life Cycle

• Family with young children (nuclear family)

APGAR

APGAR SCORE REASON

Adaptation 1 / 2 M: cannot rely on family for everything

Partnership 2 / 2 No problems in terms of communication

Growth 1 / 1 B: Family supportive but there are a lot of restrictions because of their responsibilities

Affection 2 / 2 Everyone feels loved and respected

Resolve 2 / 1 G: wants better life for his family

SCREEM

Resource Pathology

Social Good relationship within the family and within their community: neighbors

supportive and helpful

(-)

Cultural Proud of who they are and where they came from

(-)

Religious Born Again: not very religious but follows basic teachings

(-)

Economic Manages to get by with the income of the family

Frequent cause of conflict between AR’s parents, esp. about medications

Education Has clear idea on how problems arise and their solution

HS graduates only, thus have a hard time looking for high-paying jobs

Medical Very patient and diligent in going to health centers and medical missions

to avail of free services

Heavily relies on health center in their barangay and municipality; these

centers are problematic on their own

Discussion

Impact of Illness

• Stage I- Onset of Illness• Stage II- Reaction to Diagnosis• Stage III- Major Therapeutic Efforts• Stage IV- Early Adjustment to Outcome• Stage V- Adjustment to the Permanency of the

Outcome

Interventions

• Primary Caregiver• Diet modification• Consult with attending pediatric neurologist• Consult with pediatric orthopedic specialist• Linking with new health resources in the community

(KHVs/barangay)• Persistent attendance in medical missions, DSWD,

governor’s office• Make time for other children• Make time for self to avoid caregiver fatigue

Interventions

• Father• Use time at home to care for AR and support mother• Mediate with extended family if needed

• Family• Help with the day-to-day care of AR• Achieve a better diet plan for the family• Provide financial support if possible

Thank

You