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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 Interim • Intermittent hematochezia • Partially relieved with Bioenzyme and occasional intake of mesalamine • No consults done

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

  8. 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

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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

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

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

  18. 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

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

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

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

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

  23. 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

  24. Family Timeline • Diagnosed to have “severe pancolitis” • Given mesalamine, tranexamic acid and omeprazole Trajectory of Illness

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

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

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

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

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

  30. Family Timeline Trajectory of Illness

  31. Family Timeline

  32. Family Timeline Trajectory of Illness

  33. 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

  34. Family Timeline

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

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

  37. Outcome ““Doktora, mas lalong pursigido kami na bumalik….” “…May rason kung bakit kelangan mag-follow up” Assurance of cooperation and participation

  38. 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

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

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

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

  42. Education • Symptoms could recur • Possible flare ups • IBD patients in general are 6 times more likely to develop CRC than the general population • Duration of inflammation is the key factor “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

  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

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