1. BJ’S LAST TESTIMONY Family Medicine Case Presentation 15 January 2010 Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong

2. Case Background

3. General Data  23-year-old  Male  Iglesia ni Cristo  Lives in Manila

4. Chief Complaint  Cough

5. History of Present Illness  cough  unproductive  No associated symptoms (fever, colds, nausea and vomiting, change in bowel movement, dysuria)  No medications taken, no consults done 3 weeks PTA  Persistence of cough  Now associated with chest pain  Heaviness especially when coughing  3/10 pain scale  No other associated symptoms  No medications taken, no consults done 1 week PTA Cough persisted

6. History of Present Illness  Unproductive cough  Fever  Intermittent, at Tmax: 38 o C  Took paracetamol 500mg once: partial relief  Chest pain 8/10  More when coughing  Relieved when sitting down  No palpitations, syncope,  Difficulty of Breathing 1 day PTA Consult Symptoms persisted Persistence of symptoms

7. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions, no pigmentation, no pruritus HEENT: occasional headaches, no redness, no aural/nasal discharge, no neck masses, no sore throat Cardiovascular: no easy fatigability, fainting spells, palpitation

8. Review of Systems Gastrointestinal: no nausea and vomiting, no loose bowel movements, no constipation Genitourinary: no genital discharge, no pruritus, no problems in urination Endocrine: no polyuria, polydypsia, no heat/cold intolerance Hematopoietic: no easy bruisability, or bleeding

9. Past Medical History No Hypertension, Diabetes, Asthma, PTB No Cancer, Allergies, Trauma No previous surgeries No previous hospitalizations Not taking any maintenance medications

10. Family History  History of diabetes  No hypertension, heart disease, cancer, stroke, kidney disease, asthma, or allergies

11. Personal and Social History  Customer service representative, night shift  Lives alone in own apartment  Multiple unprotected sexual male and female partners  College graduate  Non-smoker  Occasional alcoholic beverage drinker  No substance abuse

12. Course in the Wards  Initially diagnosed with CAP  Started on cefuroxime and ampicillin  Patient unresponsive, started to have desaturations  Sputum sample turned out to be positive for mycobacterium, and started treatment  Shifted to levofloxacin and carbapenem  Still having desaturations and DOB, moved to ICU

13. Course in the Wards  In the ICU  Connected to a mechanical ventilator and CPAP  Still unresponsive to treatment  Now suspected to have PCP  Scheduled to have a tracheostomy Slowly weaned off CPAP Patient continuously had desaturations, then GCS 3  Family signed for DNR  Patient expired

14. Family System

16.  Patient  Single, Young adult, Lives alone  Several partners  Parents  Father works as the church minister,  Mother is the children’s primary caregiver  Family  Eldest brother, 2 younger sisters

17. Impact of Illness

18. Family Life Cycle  Launching  Goal: Being one’s own person  Secondary task Differentiation of self from family of origin Development of peer relationships

19. APGAR Almost always Some of the time Hardly ever 1.I am satisfied that I can turn to my family for help when something is troubling me.  1.I am satisfied that my family talks things over with me and shares problems with me.  1.I am satisfied that my family accepts and supports my wishes to take on new activities or directions.  1.I am satisfied that my family expresses affection and responds to my emotions, such as anger, sorrow and love.  1.I am satisfied with the way my family and I share time together.  Total Score6/10 Modified from Smilkstein G: The family APGAR: A proposal for family function test and its use by physicians, J. Family Practice 6(6), 1978. Reprinted by permission of Appleton and Lange, Inc

20. Stakeholder Analysis StakeholderInterest in IssueRoleLevel of Influence BJGetting well, Controlling my illness, Confidentiality AllyHigh MotherGetting my son well, safe and home; Keeping the family together AllyHigh FatherGetting my son well, safe and home AllyMedium SiblingsFor my brother to get well and go home soon AllyLow GrandmotherCaregiver when the mother needs to rest; For my grandson to get well and go home soon ResistorLow

21. Other Family Issues  Other family issues  Religion Iglesia ni Kristo Father is a minister  Patient’s decision and confidentiality Only the mother knew  Communication to other family members Pneumonia not responding to antibiotics Why the need to confine in an ICU

22. SCREEM Addressing Disease within a Family Framework

23. Social-Cultural-Religion-Economic- Education-Medical Tool ResourcesPathology Social Network in the workplaceLack of communication with family Cultural Harmonious relationship with colleagues Respect for parents Stigma for possible venereal disease Religion There are no religious differences in dealing with the sick among Iglesia Ni Cristo Conservative group who would disapprove of the illness Economic Personal income Empowerment to make own financial decisions Family members are open to financially assisting Expensive medical care requirements No known savings yet Education Patient is a college graduate who is able to comprehend the medical needs required for his illness Medical Health card holder and immediate access to health needs, improving health seeking behavior Non-coverage for illness related to risky lifestyle behaviors In a tertiary hospital with high price for health care without his HMO coverage

24. MEDICAL ISSUES

25. ICU: Family Meetings  “Screened” family meetings  Patient’s wishes of confidentiality  Treatment and current status of patient  Focused on issues regarding management of pneumonia  Family members and roles Mother: confided with father Father: decision maker Sisters: support group Grandmother: active spokesperson

26. HIV Management  Medical and Psychological  address symptoms  address depression  Social and Legal  Contact tracing and screening  Confidentiality  Difficulty obtaining consent for HIV testing  CD4 count as alternative  Delayed aggressive treatment

27. Psychosocial Issues

28.  STIGMA Societal stigma Homosexuality: acceptable to society? Religious stigma Having the infection as a sign of moral fault

29. Psychosocial Issues  Financial burden  Issue with HMO coverage for lifestyle-related diseases

30. Psychosocial Issues  Communication barrier  Psychosocial profile of family  Cultural issues on HIV and homosexuality  DNR and INC doctrines about life No clear practice on remembering those who died No doctrine on the issue of DNR

31. Psychosocial Issues  Bereavement and Acceptance of loss No clear understanding of how this came about Difficult to communicate to family members the reason for BJ’s confinement The issue of communicating his testimony to their community

32. Family Wellness Plan

33.  Identify family support roles  Father as source of strength  Iglesia ni Cristo community  Delve deeper on grief and bereavement  Family counseling regarding their own feelings towards the loss

34. Family Wellness Plan  End goal regardless of religion would be the overall acceptance of the situation and the ability to reach a new equilibrium beyond the death of their loved one.

35. Learnings as a Physician

36. Learnings as a physician  More than diagnosis and management  RAPPORT  Trust between physician and patient is the key to open up the process of revealing important information

37. Learnings as a physician  PHYSICIAN = ADVOCATE  Equipped with the Right Tools, Right frame of mind  Responsibility of a physician- advocate  Ensure that patient is well informed  Prevent stigma in healthcare setting  Holistic approach – family is the key

38. Every physician should be an advocate for each patient. Equipped with the right tools and the right frame of mind, we begin to realize that illness can be utilized to serve the good of the patient and the family. Illness is associated with grief and loss of hope, but if we open up our minds and look closer, we will see that Illness also paves the way to unity and healing- for the patient, family, and physician.

39. BJ’S LAST TESTIMONY Family Medicine Case Presentation 15 January 2010 Group 7 Asuncion-Dalman-Doromal-Dy-Generoso-Mejia-Ong