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Ripples

Ripples. A Family Case Presentation Avegail S. Estrella, MD 2 nd Year Resident UP-PGH DFCM. Objectives. To present a family of a patient with ulcerative colitis To discuss the interaction between ulcerative colitis and the dynamics of the family

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Ripples

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  1. Ripples A Family Case Presentation Avegail S. Estrella, MD 2nd Year Resident UP-PGH DFCM

  2. Objectives • To present a family of a patient with ulcerative colitis • To discuss the interaction between ulcerative colitis and the dynamics of the family • To analyze the family dynamics using available family assessment tools • To discuss the role of a family physician in caring for a patient with ulcerative colitis and her family • To formulate a wellness plan for the family

  3. Patient Profile J.P. 21 y/F Single Roman Catholic Cavite Hematochezia

  4. Medical History 2 years PTC • Intermittent Hematochezia • Colicky abdominal pain • Initial consult: University Medical Center • Blood Transfusion • Colonoscopy: Severe Pancolitis • Mesalamine • Discharged improved and stable

  5. Medical History 2 years PTC • Lost to follow-up • 5 months after hospitalization • Recurrence of symptoms • No medical consultations • Tried herbal remedies

  6. Medical History 3 days PTC • Persistent hematochezia • Occasional dizziness • Pallor • No altered sensorium, easy fatigability, dyspnea, palpitations, generalized weakness • FMC consult

  7. Review of Systems • No insomnia, headache, blurring of vision • No jaundice, skin rashes, cyanosis • No cough, colds, sore throat, sensation of lump in the throat • No chest pain, PND, orthopnea • No dysuria, intermittency, frequency • No joint pains, edema

  8. Past Medical History • Not known asthmatic • No previous operations • No known food or drug allergies • Not known hypertensive or diabetic

  9. Menstrual and Gyne History • Nulligravid • M – 12 y.o. • I – 28-30 days • D – 5-4 days • A – 3-4 pads/day • S – (+) dysmenorrhea on day 1 • LMP: June 26, 2011 • PMP: May 24, 2011 • No sexual contact

  10. Personal and Social History • Non-smoker • Not an alcoholic beverage drinker • Denied illicit drug use • Diet: mostly fish and vegetables • Occasional meat and fruit consumption • Meals prepared at home

  11. Environmental History • Lives in a 2 bedroom, concrete bungalow-type house • Commercially purified drinking water • No pets around the house • No similar symptoms among other household members and in the community

  12. Physical Examination • Conscious, coherent, ambulatory, not in distress • Vital Signs BP 100/70 PR 98 RR 19 Temp 36.9C Height 151 cm Weight 45 kg BMI 19.7 • (+) Pale lips and palms; warm, moist skin, no active dermatoses • Pale palpebral conjunctivae, anicteric sclerae

  13. Physical Examination • Moist buccal mucosa, no tonsillopharyngeal congestion • Supple neck, no anterior neck mass, no cervical lymphadenopathies • Symmetric chest expansion, no retractions, clear and equal breath sounds, no wheezes, no crackles

  14. Physical Examination • Adynamic precordium, AB 5th LICS, MCL, no murmurs • Flat abdomen, normoactive bowel sounds, soft, non-tender, no organomegaly • DRE: no perianal lesions; tight sphincteric tone, full rectal vault, smooth rectal mucosa; no masses, no tenderness; (+) blood per examining finger • Pulses full and equal

  15. Physical Examination • t/c Inflammatory Bowel Disease • Anemia probably secondary to LGIB probably secondary to Inflammatory Bowel Disease

  16. Plans Diagnostics: • CBC • Fecalysis with FOBT Therapeutics: • Restart mesalamine 500mg/tab, 2 tablets, TID • Refer to GI for possible colonoscopy

  17. Course • CBC revealed severe anemia • Admitted in ward 4 • Working impression: Inflammatory Bowel Disease (Ulcerative colitis vsCrohn’s Disease) • Blood transfusion • Colonoscopy with biopsy was done • Medications: Mesalamine, Omeprazole and Metronidazole

  18. Palle – Zacarias Family January 27, 2012 Janet 43 Jaime 44 Jhamie 21 Jeffrey 17 HPN (-) DM, asthma (-) Blood dyscrasia, CA (-) Similar symptoms/ illness

  19. Family Timeline • Jhamie’s High School graduation • She decided to pursue nursing • Mang Jaime left for Guam Trajectory of Illness

  20. Family Timeline • Role reorganization and adjustments • Worked together to reach new equilibrium Trajectory of Illness

  21. Family Timeline • Found new equilibrium • Onset of Jhamie’s symptoms • - initially blood streaked stools • Jhamie was admitted at UMC Trajectory of Illness

  22. Family Timeline • Jhamie was hesitant to inform her mother • Afraid to disrupt the newly found equilibrium • Aling Janet feared that it is something serious Trajectory of Illness

  23. Family Timeline • Diagnosed to have “severe pancolitis” • Symptoms controlled Trajectory of Illness

  24. Family Timeline • Unable to grasp the meaning of the diagnosis • Goal: become symptom free • Lost to follow-up Trajectory of Illness

  25. Family Timeline • Intermittent symptom recurrences • Tried herbal remedies • Hopeful that symptoms can be controlled without medical consultation Trajectory of Illness

  26. Family Timeline • Still with symptom recurrences • Mang Jaime’s contract ended • Financial difficulties • Avoided medical consultation Trajectory of Illness

  27. Family Timeline • Hematochezia became persistent • No relief with herbal remedies • Caused enough stress • Decided to seek consult at PGH Trajectory of Illness

  28. Family Timeline • Ward admission • The whole family stayed with Jhamie Trajectory of Illness

  29. Family Timeline Trajectory of Illness

  30. Family Timeline Trajectory of Illness

  31. Family Timeline Trajectory of Illness

  32. 2009 Family Timeline • UMC • Blood Transfusion • Colonoscopy • 5-ASA agent (Mesalamine) • Lost to follow-up • PGH • Blood Transfusion • Colonoscopy • 5-ASA agent (Mesalamine) • Will she follow-up? Trajectory of Illness

  33. Family Timeline

  34. Patients’ reasons for non-compliance Hawthorne AB, 2008

  35. Purpose of Follow-up • Disclosure of diagnosis • Discussion about the disease • Discussion about treatment options • Goal setting

  36. Outcome ““Doktora, mas lalong pursigido kami na bumalik….” “…May rason kung bakit kelangan mag-follow up”

  37. Ulcerative Colitis • Diffuse mucosal inflammation of the colon • Immune-mediated disorder • PGH Experience • 22 IBD cases (1999 to 2004) • 18 had Crohn’s disease • 4 had Ulcerative colitis

  38. Psychosocial Typology of Illness Course of Chronic Illness • Progressive – RA, alzheimers, CA • Constant – stroke, trauma • Relapsing/Episodic – ulcerative colitis • Requires flexibility • “On Call”

  39. Family CEA • Aling Janet, Mang Jaime and Jhamie

  40. Catharsis “Isa dawpoitonguringpamamagangbituka…” “Kelanganuminomnggamot” “Maaaringumulit…” “Maaridaw pong lumala at mauwisa colon cancer”

  41. Education • Symptoms could recur • Possible flare ups “Regular use of 5-ASA therapy significantly reduces the risk of developing CRC in up to 75% in UC patients in the long term” Van StaaTP, 2005

  42. Education Colorectal cancer (CRC) risk for patients with ulcerative colitis 2% after 10 years 8% after 20 years 18% after 30 years Mean duration from the time of diagnosis of ulcerative colitis to development of possible CRC is 17 years. Eaden, 2004

  43. Action • Will be cooperative and compliant • Adhere to follow-up schedules and future surveillance “Angakalapokasinamin, automatic namagkakaroonnasiyang cancer..” “Nungnabanggitpokasiyungsalitang cancer, parangwalanapokamingibangnadinig…”

  44. Outcome • Improved condition • Dosage adjustments • Return to previous functioning

  45. Stumbling Block • Limited finances • Mesalamine 500mg tablet costs P70.00 • Current dosage: 4 tablets/day = P280.00/day

  46. SCREEM

  47. Family Timeline • Gradual movement from the role of being sick to some form of recovery or adaptation Trajectory of Illness

  48. Family Timeline Trajectory of Illness

  49. Family Timeline • Accept and adjust to a permanent disability • Chronic relapsing course • Life must go forward Trajectory of Illness

  50. The Unaffected Sibling • Jeffrey is aware of his sister’s (Jhamie) condition • Concern for his sister • He felt he is involved

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