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Chong Hua Hospital Mandaue

Department of Family and Community Medicine

A BREATHLESS STRUGGLE:
UNVEILING PNEUMONIA IN A 26-YEAR-OLD FEMALE WITH COUGH AND DYSPNEA

In Partial Fulfillment of the Requirements for Community Medicine

Submitted by: Group 5 PGI

REJULIO, CRYSTAL MAE D.

October 24,, 2024

I. Objectives:

•​ To discuss a case of a 26-year-old female who presented with cough and difficulty
breathing
•​ To discuss the clinical manifestations, differential diagnoses, diagnostics, and
management of patients with Community Acquired Pneumonia-Moderate Risk
•​ To present the family profile and discus the family dynamics of BOHOL-AGAD family
using the family assessment tools

II. THE CASE

GENERAL DATA:
​ A.A.A, a 26 year old female, single, born on April 10, 1998, Roman Catholic, currently
working as a Billing Specialist at CHHM Renal Unit, residing at General Maxilom Ext. Carreta
Cebu City came in at CHHM ED due to difficulty breathing and cough

CHIEF COMPLAINT:
​ Difficulty breathing and cough

HISTORY OF PRESENT ILLNESS:

​ 5 days PTA, patient noted onset of dry cough and coryza. Patient tolerated symptoms.
No consult done.
2 days PTA, noted onset of productive cough, coryza, now associated with difficulty
breathing, dizziness, undocumented low grade fever, and squeezing headache. She took
neozep and decolgen without relief.
Morning prior, worsening and persistence of symptoms prompted the patient to seek
consultation at the Er and subsequent admission.

PAST MEDICAL HISTORY

The patient has no history of hypertension, diabetes mellitus, or asthma.

In November 2023, she was diagnosed with anemia secondary to abnormal uterine
bleeding. Additionally, in 2020, the patient was diagnosed with Non-Hodgkin’s Lymphoma.

She has no known food or drug allergies.

FAMILY HISTORY
The patient reports no known heredofamilial diseases, except for a history of breast
 cancer on the maternal side.

MENSTRUAL HISTORY
The patient began sexual activity at 18 years old. She has had two sexual partners and
is currently in a same-sex relationship.

SEXUAL HISTORY
The patient began sexual activity at 18 years old. She has had two sexual partners and
is currently in a same-sex relationship.

PERSONAL AND SOCIAL HISTORY

The patient works as a billing specialist in the Renal Department at CHHM. She resides
in an apartment made of hardwood in Barangay Carreta, Cebu City, where she lives with her
parents and five siblings, being the second of eight children.

Her diet primarily consists of rice, meat, chicken, vegetables, and fruits, and she typically
purchases her meals from a carenderia. She is restricted from consuming "kinilaw." The patient
drinks more than two liters of water daily, urinates more than five times a day, and has bowel
movements five to six times per week. She does not smoke but occasionally consumes
alcoholic beverages.

In terms of environmental exposures, she is regularly exposed to smoke at home, as her father
and male siblings smoke cigarettes and vape. At work in the Renal Unit, she is frequently in
contact with individuals who have cough.

PHYSICAL EXAMINATION:
General Survey: Examined an alert, conscious, cooperative patient, and in respiratory distress
with the following vital signs:

Vital signs:
BP: 100/70 mmHg
RR: 26 CPM
Temperature: 36.4 C
HR: 110 bpm
O2 sat: 99% at RA
Height: 149.9 cm
Weight: 70 kg
BMI: 31.2 (Class 1 Obesity)
Skin: Skin is fair, warm, dry, smooth to touch with good skin mobility and skin turgor and no
jaundice present. Nails have no signs of clubbing or cyanosis. There are no suspicious macules,
nevi, rash, hematoma, petechiae, or ecchymoses present on the patient’s skin.

HEENT:
Head: Skull is normocephalic, symmetrical. No baldness, flakes, scales, and lumps seen on the
scalp.
Eyes: Well-aligned with no deviations nor protrusions. Eyebrows are evenly distributed with no
flakes. Equal palpebral fissures with eyelashes directed outwards, pinkish palpebral
conjunctivae, anicteric sclerae, transparent cornea. Pupils are equally reactive to light both
direct and consensual. Full range extraocular muscle movements is observed by the Finger
Following Test with good convergence. Able to read newsprint with ease at 2 feet distance with
both eyes.

Ears: No deformities, tenderness, and discharges. Tympanic membranes are pearly gray and
intact bilaterally with a good cone of light. Able to hear Whispered voice at 2 feet distance.
Weber midline. Rinne AC>BC.
Nose and Paranasal Sinuses: No deformities, alar flaring, discharges, and tenderness of
paranasal sinuses. Able to transilluminate. Nasal septum midline. Nasal mucosa is pink.

Mouth and Pharynx: Lips are red and moist. Buccal mucosa is pink with no lesions. Tongue is
on the midline on protrusion with no lesions. Uvula is on the midline . (+) hyperemic tonsillar
pillars

Neck: Trachea is at the midline. Neck veins are not engorged or distended. No carotid bruits or
thrills present.

Chest and Lungs: Thorax is symmetric with good expansion, no deformities, scars, and
intercostal retractions. No palpable tenderness, bruises and masses. Equal tactile fremitus is
present and lungs are resonant. (+) Rales on left lower lung field

CVS: Carotid upstrokes are brisk without bruits. No thrills, heaves, and tenderness. (+)
tachycardia. no murmurs nor thrills
PVS: Strong radial, brachial, femoral, popliteal, posterior tibial and dorsalis pedis pulses with
good return flush on Allen’s test. No pedal edema, and varicosities. Extremities are warm
without edema and no varicosities or stasis changes. Calves are supple and nontender. No
femoral or abdominal bruits. CRT <2. Brachia, radial, femoral, popliteal, DP, and PT pulses are
3+ and symmetric.

Abdomen: Abdomen is flabby with normoactive bowel sounds. no tenderness. It is soft with no
palpable masses or hepatosplenomegaly. Spleen and kidneys are not palpable.

GUT: (+) KPS PS 3/10

Rectum: DRE not done

Female Genitalia:.Grossly female

Musculoskeletal: Full range of motion in all joints of the upper and lower extremities. No
evidence of swelling or deformity.

Neurologic Examination:

Mental Status: Patient is awake, conscious, active, and cooperative. She is oriented to person,
place, and time. Recent and remote memory are both intact. Speech is fluent and words are
clear. Thought process, content, and insight are all intact.

Cranial nerves:
I - patient is able to identify the smell of coffee grounds through both nostrils
II - both pupils are equal, round, reactive to both light and accommodation, 20/20 visual acuity
by Jaegers chart​
III, IV, VI - full range of extraocular muscle movements are observed by the Finger Following
Test with good convergence
V - patient is able to clench the teeth, open, and move the jaw from side to side, positive corneal
reflex on both eyes are observed by the Blink Test
VII - no facial asymmetry
VIII - patient is able to hear whispered voice at 2 feet
IX, X - patient is able to swallow and gag reflex is present
XI - patient is able to shrug shoulders bilaterally against resistance​
XII - tongue and uvula is at the midline

Motor: Good muscle bulk and tone. Strength 5/5 throughout.

Cerebellar: Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S)
intact. Gait with normal base. Romberg—maintains balance with eyes closed. No pronator drift.
Sensory: Pinprick, light touch, position, and vibration intact.
Reflexes: 2 and symmetric with plantar reflexes downgoing.

SALIENT FEATURES
We are presented with the case of A.A.A., a 26-year-old female working as a billing
analyst in the Renal Unit, who presented with dyspnea. Pertinent findings on history and
examination include a productive cough, coryza, dyspnea, headache, dizziness, and an
undocumented fever. She reported regular exposure to patients with cough at her workplace.
On physical examination, her heart rate was 110 beats per minute, and her respiratory rate was
26 breaths per minute. Auscultation revealed rales in the left lower lung field, and inspection of
the oropharynx showed hyperemic tonsillar pillars.​ ​
III. CLINICAL FORMULATION

PRIMARY IMPRESSION
Community acquired Pneumonia- low risk

Pneumonia is an infection of the pulmonary parenchyma. Despite significant morbidity

and mortality, it is often misdiagnosed, mistreated, and underestimated. Pneumonia has usually
been classified as community-acquired (CAP), hospital-acquired (HAP), or ventilator-associated
(VAP). m. Risk factors for infection with MRSA and Pseudomonas aeruginosa include prior
isolation of the organism, particularly from the respiratory tract during the preceding year, and/
or hospitalization and treatment with an antibiotic in the previous 90 days, which, the index
patient would be a risk factor as she has taken azithromycin a month prior.
Pathophysiology:
Pneumonia is the result of the proliferation of microbial pathogens at the alveolar level
and the host’s response to them. Until recently, it was thought that the lungs were sterile and
that pneumonia resulted from the introduction of potential pathogens into this sterile
environment. Typically, this introduction occurred through microaspiration of oropharyngeal
organisms into the lower respiratory tract. Overcoming of innate and adaptive immunity by such
microorganisms could result in the clinical syndrome of pneumonia.
An inflammatory event resulting in epithelial and or endothelial injury results in the
release of cytokines, chemokines, and catecholamines, some of which may selectively promote
the growth of certain bacteria, such as Streptococcus pneumoniae and P. aeruginosa. This cycle
of inflammation, enhanced nutrient availability, and release of potential bacterial growth factors
may result in a positive feedback loop that further accelerates inflammation and the growth of
particular bacteria, which may then become dominant. In cases of CAP and HAP, the trigger
may be a viral infection compounded by microaspiration of oropharyngeal organisms. In cases
of true aspiration pneumonia, the trigger may simply be the macroaspiration event itself. Once
triggered, innate and adaptive immune responses can ideally help contain potential pathogens
and prevent the development of pneumonia. However, in the face of continuing inflammation
(and especially if a positive feedback loop becomes sustainable), the process may proceed to a
full-fledged pneumonia syndrome. Inflammatory mediators such as interleukin 6 and tumor
necrosis factor result in fever, and chemokines such as interleukin 8 and granulocyte
colony-stimulating factor increase local neutrophil numbers. Mediators released by
macrophages and neutrophils may create an alveolar capillary leak resulting in impaired
oxygenation, hypoxemia, and radiographic infiltrates. Moreover, some bacterial pathogens
appear to interfere with the hypoxic vasoconstriction that would normally occur with fluid-filled
alveoli, and this interference may result in severe hypoxemia. Decreased compliance due to
capillary leak, hypoxemia, increased respiratory drive, increased secretions, and occasionally
infection-related bronchospasm all lead to worsening dyspnea. If severe enough, changes in
lung mechanics secondary to reductions in lung volume, compliance, and intrapulmonary
shunting of blood may cause respiratory failure.
Clinical manifestation:
The clinical presentation of pneumonia can vary from indolent to fulminant and from mild
to fatal in severity. Manifestations of worsening severity include both constitutional findings and
those limited to the lung and associated structures. The patient is frequently febrile and/ or
tachycardic and may experience chills and/or sweats. Cough may be nonproductive or
productive of mucoid, purulent, or blood-tinged sputum. Gross hemoptysis is suggestive of
necrotizing pneumonia (e.g., that due to CA-MRSA). Depending on severity, the patient may be
able to speak in full sentences or may be short of breath. With pleural involvement, the patient
may experience pleuritic chest pain. Up to 20% of patients may have gastrointestinal symptoms
such as nausea, vomiting, or diarrhea. Other symptoms may include fatigue, headache,
myalgias, and arthralgias. Findings on physical examination vary with the degree of pulmonary
consolidation and the presence or absence of a significant pleural effusion. An increased
respiratory rate and use of accessory muscles of respiration are common. Palpation may reveal
increased or decreased tactile fremitus, and the percussion note can vary from dull to flat,
reflecting underlying consolidated lung and pleural fluid, respectively. Crackles, bronchial breath
sounds, and possibly a pleural friction rub may be heard. The clinical presentation may be less
obvious in the elderly, who may initially display new-onset or worsening confusion but few other
manifestations. Severely ill patients may have septic shock and evidence of organ failure. In
cases of CAP, symptoms can range from almost nonexistent to severe, and chest radiographic
findings are often in gravity-dependent parts of the lung.

DIFFERENTIAL DIAGNOSIS

Acute Bronchitis

Acute bronchitis is a potential diagnosis in this case due to the patient’s productive cough,
coryza, and dyspnea, which are hallmark symptoms of bronchial inflammation. Bronchitis is
typically viral but can also be bacterial, presenting with cough that may last several weeks. The
absence of significant lung consolidation on imaging, if confirmed, would favor bronchitis over
pneumonia. However, the presence of localized rales in the left lower lung field raises the
possibility of more serious lower respiratory tract involvement, making pneumonia a stronger
consideration than acute bronchitis alone.

Influenza

Influenza is a likely consideration due to the patient's symptoms of fever, cough, headache, and
generalized body weakness. The patient’s exposure to individuals with respiratory infections at
her workplace further supports this possibility. Influenza can cause upper and lower respiratory
symptoms, and although it is primarily a viral illness, it may lead to secondary bacterial
infections such as pneumonia, which could explain the localized rales on physical examination.

COVID-19

Given the ongoing prevalence of COVID-19 and the patient’s exposure to individuals with
respiratory illnesses, COVID-19 is an important differential diagnosis. COVID-19 can present
with a wide range of symptoms including cough, dyspnea, fever, headache, and body
weakness. The presence of rales on auscultation raises concern for possible viral pneumonitis
or secondary bacterial pneumonia. Diagnostic testing for COVID-19 would be essential to
confirm or rule out this possibility, as it remains a common cause of respiratory illness in
healthcare settings.

Acute Tonsillopharyngitis

Acute tonsillopharyngitis is also a differential diagnosis, particularly given the presence of

hyperemic tonsillar pillars, which are indicative of inflammation in the oropharynx. This condition
is usually viral but can also be bacterial, with group A streptococcus being a common pathogen.
While acute tonsillopharyngitis typically presents with sore throat and systemic symptoms such
as fever and headache, it does not usually cause localized lung findings like rales. Thus, while
this diagnosis may explain some of the upper respiratory symptoms, it is less likely to account
for the patient’s lung findings.

DIAGNOSTICS
Upon arrival at the emergency room, a series of laboratory tests were ordered to further
evaluate the patient’s condition. These included CBC, urinalysis, serum Na and K, creatinine,
SGPT, chest X-ray (PA view), 12L ECG, and a COVID Rapid Duo test.

COMPLETE BLOOD COUNT

WBC 9.2 4.8-10.8

Neu 54.9 40-74

Lym 29.7 19-48

Mono 7.1 3.4-9.0

Eos 7.7 0-7

Baso 0.6 0-1.5

RBC 4.63 4.2-5.4

Hgb 13.1 12-16

Hct 39.4 37-47

Platelet 322 130-400

MCV 85.1 81-99

MCH 28.4 27-31

MCHC 33.3 33-37

RDW 12.9 11-16

COVID 19 RAPID ANTIGEN/ FLU A AND B TEST:
NEGATIVE

THERAPEUTICS
●​ ANTIBIOTICS:
○​ Piperacillin-tazobactam 4.5g IVTT q8
○​ Clarithromycin 500mg tab PO OD
●​ MUCOLYTIC AGENT:
 ○​ Acetylcysteine 600mg tab PO BID
●​ LEUKOTRIENE RECEPTOR ANTAGONIST
○​ Levocetirizine + montelukast (zykast) 5/10 mg tab OD HS
●​ BRONCHODILATOR
○​ Duavent 1 neb q12
●​ Nafarin-A 1 tab PO TID RTC
For empiric treatment of low-risk CAP, we recommend the use of the following:
Patients with low risk CAP without comorbidities:
Amoxicillin 1 gram, three times daily (Strong recommendation, low quality of evidence)
OR
Clarithromycin 500mg, twice daily OR
Azithromycin 500mg once daily (Strong Recommendation, low quality of evidence)
Risk for Pseudomonas aeruginosa
• Prior colonization or infection with P aeruginosa within 1 year
• Severe bronchopulmonary disease (severe COPD, bronchiectasis, prior
tracheostomy)
REPLACE Non-pseudomonal Beta lactam antibiotic with:
Piperacillin-Tazobactam 4.5g IV every 6 hours OR
Cefepime 2 g IV every 8 hours OR
Ceftazidime 2 g IV every 8 hours OR
Aztreonam 2 g IV every 8 hours OR
Meropenem 1 g IV every 8 hours (especially if with ESBL risk)
PLUS Macrolide OR respiratory fluoroquinolone

PROGRESS NOTES

HOSPITAL DAY 1 (10/22/24)

S Awake, alert, NIRD. still complains with cough and headache

O (+) rales left lower lung field

A CAP-LR

P Continue medications
●​ Piperacillin-tazobactam 4.5g IVTT q8
●​ Duavent 1 neb q8
●​ Nafarin A q8
IVF PNSS 1l at 120 cc/hr
 HOSPITAL DAY 2 (10/23/24)

S Awake, alert, NIRD. still complains with cough and headache

O (+) rales left lower lung field

A CAP-LR

P Continue medications
●​ Piperacillin-tazobactam 4.5g IVTT q8
●​ Levocetirizine + montelukast (zykast) 5/10 mg tab OD HSAcetylcysteine 600mg tab PO BID
●​ Decrease Duavent inhalation to q12
●​ increase Nafarin-A to 1 tab PO TID RTC
●​ Add Clarithromycin 500mg tab PO OD after meals
Decrease IVF to 60 cc/hr

IV. FAMILY ASSESSMENT TOOLS

SITUATIONAL ANALYSIS

The patient currently lives in an apartment in Brgy Carreta, Cebu City together with her
parents and and 5 other siblings. They are renting 3 rooms each costing Php2000/room
amounting to Php 6000/month. The house is made up of wood and they are staying in the 2nd
floor. They have been living in their current house since the patient was in elementary school.
Her house is situated 3.4 km from Chong Hua Hospital Mandaue, where she is currently
working, with a usual travel time of 8 mins by car, 8 mins by motorcycle, and 46 mins by foot.
They share the electric meter and water meter with the landlady of the apartment they
are renting.

FAMILY PROFILE AND ROLES

F.B, 46/M
●​ Father
●​ Elementary level
●​ Used to be a jeepney driver and the sole breadwinner of the family
●​ Now stays at home and takes care of chickens owned by neighbour
●​ Smoker 5 pack-years
●​ No known comorbidities as claimed
●​ Caregiver and Homemaker

E.A. 27/F
●​ Mother
●​ Highschool level
●​ Housewife who works as a cleaner as sideline
●​ No known comorbidities as claimed
●​ Caregiver, Homemaker and Decision Maker

A.A 26/ F
●​ Index patient
●​ 2nd eldest
●​ College graduate
●​ Works as Billing Analyst at CHHM Renal Unit for 5 years now
●​ History of Non-Hodgkin’s lymphoma
●​ Breadwinner

M.A. 27/F
●​ Eldest sister of the index patient
●​ College level
●​ Works at a Call center
●​ Currently not living at home but visits often
●​ Breadwinner and Decision Maker

M.A, 24/M
●​ 3rd sibling
●​ Senior highschool level
●​ Currently not living at home but visits sometimes
●​ Used to be a weightlifter
●​ Currently stays at home but sidelines as a coach
●​ No known comorbidities as claimed
 ●​ Smokes vape

F.J.A, 22/M
●​ 4th sibling
●​ 2nd year college (Criminology at UC)
●​ Weightlifter and member of the national team
●​ No known comorbidities as claimed
●​ Vapes
●​ Provides additional financial aid

JDA, 18/M
●​ 5th sibling
●​ Senior highschool student at UC
●​ Weightlifter and a former member of the national team
●​ No known comorbidities as claimed
●​ Vapes

NB, 16/M
●​ 6th sibling
●​ Senior high school student at ACT
●​ No known comorbidities as claimed
●​ Vapes

A.B., 14/F
●​ 7th sibling
●​ Highschool student at Carreta night high school
●​ No known comorbidities as claimed

S.B., 12/F
●​ Youngest sibling
●​ Grade 6 student at Carreta elementary school
●​ No known comorbidities as claimed
FAMILY GENOGRAM

FAMILY INCOME AND EXPENSES

The family’s total monthly income is estimated to be around Php 60,000 per month which
makes them a part of the Middle-Middle class. This is from the accumulated salary of the index
patient and her older sister and the allowance that her brother recieves from the Weightlifting
National team.

SOURCE AMOUNT
MONA 30,000
APRIL 20,000
FERNANDO 10,000

​ The family's total monthly expenses amount to approximately Php 59,000. This includes
Php 6,000 for house rent, Php 2,000 for electricity, Php 1,000 for water, and Php 1,000 for Wi-Fi.
Their phone bills total Php 2,400 each month. For food, the family spends about Php 27,000
monthly, while tuition fees amount to Php 3,500. An additional Php 12,000 is allocated for
allowances, and Php 5,000 is spent on other necessities. In total, their monthly expenditures
reach Php 59,900.
EXPENSES AMOUNT
HOUSE RENT 6000
ELECTRICITY 2000
WATER 1000
WIFI 1000
PHONE BILLS 2400
FOOD 27000
TUITION 3500
ALLOWANCE 12000
NECESSITIES 5000
TOTAL 59900

FAMILY CIRCLE

Family circle metaphorically reflects the closeness of relationships as well as the

common experiences that connect the family members together.
This family circle, made by the index patient, shows both the index patient’s family, and
those who are close to her, which is mostly made up of her family members. We can infer from
this illustration that she is more close to her mother and Mona compared to her father and other
siblings.

FAMILY LIFELINE
Family lifeline summarizes the individual or family’s significant experiences/events over a
period of time in a chronological-sequence manner. The presentation of their life events allows
exploration of family issue that identifies the factors that may affect the health of the family.

YEAR LIFE EVENT IMPACT

2016 Summer camp at Badian and met her first girlfriend +++++

2017 1st heartbreak -----

2019 Graduated college and got her first job +++++

2020 Got diagnosed with Non-Hodgkin’s lymphoma -----

Pandemic happened

2022 Celebrated new year at girlfriend’s house +++++

2023 Went to Bohol to celebrate great-grandmother’s 100th +++++

birthday and had a mini-reunion with the mother’s side of
the family

2024 First outside of Cebu trip going to Boracay with friends +++++

FAMILY APGAR I
The APGAR I is a five-item questionnaire that assesses the family’s functionality, and is
a rapid screening tool for family dysfunction. It is designed to measure the patient’s level of
satisfaction about the family’s relationship, and tests five areas of family function. It is often used
when: (1) the family will be directly involved in caring for the patient (2) treating a new patient to
get information to serve as a general view of family function; (3) treating a patient whose family
is in crisis; (4) when a patient’s behavior makes you suspect a psychosocial problem that is
possibly due to family dysfunction.
 The patient mentioned that, as a family, they rarely open up to one another and do not
discuss personal matters, especially problems. She explained that one reason for not sharing
her concerns is her desire not to burden her family, preferring to keep her issues to herself and
solve them on her own.

A.A

A I am satisfied that I can turn to my family for 1

help when something is troubling me.

P I am satisfied with the way my family talks 1

about things with me and shares problems with
me.

G I am satisfied that my family accepts and 1

supports my wishes to take on new activities or
directions.

A I am satisfied with the way my family expresses 1

affection and responds to my emotions such as
anger, sorrow, and love.

R I am satisfied with the way my family and I 1

share time together.

Total score 5

Interpretation MODERATELY DYSFUNCTIONAL

FAMILY APGAR II
Family APGAR II is used to delineate the patient’s relationship with the other members of the
family, and allows identification of the main caretaker. The patient gets along fairly with the
members of her family,

Who lives in your home? How well do you get along?

Name Relationship Age Sex Well Fairly Poor

FERNANDO BOHOL Mother 46 M ✓

ELISA AGAD Father 49 F ✓

FERNANDO JR AGAD Brother 22 M ✓

JOHN DOMINIC BOHOL Brother 19 M ✓

NINO BOHOL Brother 16 M ✓

ASHLEY BOHOL Sister 14 F ✓

SHANELLE BOHOL Sister 12 F ✓

If you don’t live with your family, list the persons whom you turn How well do you get along?
to for help

Name Relationship Age Sex Well Fairly Poor

MONA AGAD Sister 27 F ✓

MARJUN AGAD Brother 26 M ✓

SCREEM ANALYSIS

STRENGTH PATHOLOGY

SOCIAL
The patient is lives with her immediate Does not really interact much with her
family in the same house family since patient’s work takes up
most of her time with only 1 day off per
Patient has friends and colleagues week. This could lead to
and a partner which she can talk to. miscommunication within the family

CULTURAL
The patient believes in the Filipino
tight knit family culture. Even though
they arent the type to open up
No significant weaknesses identified
emotionally, she still wants to have
communication with her siblings that
live far away.
RELIGIOUS
Patient finds strength in her faith most They as a family don't really go to
especially during the times of illness church often.

EDUCATIONAL
The patient has little regret that her
The patient believes that her family
elder sister was not able to finish
has sufficient education, enabling
college as this would have lead to her
them to handle day-to-day problems
finding better suited job.

ECONOMIC
2 out of the family members have a Patient still finds their income
stable job while 3 of the members insufficient as they are many in the
have part time jobs that gives family so they still find themselves in
additional financial aid to the fmaily debt.

The patient has easy access to

MEDICAL Not all members have insurance.
medical assistance as she is working
Family members have poor health
in the hospital while her elder sister
seeking beheviour
has insurance that covers her parents
 QUESTIONS SA (3) A (2) D SD (0)
(1)
SOCIAL We help each other in our family. ✓
We are helped by friends and other
members of the community.
CULTURAL Our culture gives our family strength. ✓
A culture of helping and cooperation in our
community helps our family.

RELIGIOUS Our faith and religion help our family. ✓

We are helped by members of our church
or other religious groups.
EDUCATIONA Our education/ knowledge is adequate to ✓
L understand information about the illness.
Our education/ knowledge is adequate to
care for the patient.

ECONOMIC Our family's savings are adequate for our ✓

needs.
Our family's income is adequate to care for
the patient.

MEDICAL It is easy to access medical help in our ✓

community.
We are helped by doctors, nurses, and
health workers.

SA = Strongly Agree, A = Agree, D = Disagree, SD = Strongly Disagree

Scoring: 13-18 adequate ; 7-12 Moderately inadequate ; 0-6 severely inadequate
TOTAL: 17 - Adequate
FAMILY MAP

In this family map, we can see that they have functional relationship defined by clear
boundaries between each of the patient’s family members. Although she has a good relationship
with her family, they seldom talk about their problems and they seldom show their affection
towards each other

FAMILY ECOMAP

The family ecomap summarizes complex data and information into a visual, easy to see
and understand format to support understanding and planning. It is a visual representation or
diagram that illustrates the relationships and interactions between an individual or a family and
their social environment. The arrows indicate the nature of the connection between individuals,
families, or other entities represented on the diagram.
​ The patient works as a billing specialist at Chong Hua Hospital Mandaue where she is
covered by the hospital’s ABL, which covers a significant portion of her medical expenses thus
lessens her stress regarding her hospitalization.

FAMILY LIFE CYCLE

First Order Changes in the Family Life Cycle: Launching Children

As the patient and her family navigate the transition associated with launching children,
they encounter several first-order changes that impact their dynamics and overall functioning.

Health Management Adjustments​

​ One significant adjustment is related to health management. With children transitioning
into adulthood, the family may need to re-evaluate their health care priorities. This could involve
encouraging healthy lifestyle choices and fostering greater independence in managing health.
The patient may feel a heightened responsibility to model positive health behaviors, leading to
discussions about regular medical check-ups, nutrition, and mental well-being. Furthermore,
addressing any chronic health issues within the family becomes crucial as they seek to establish
a supportive environment that prioritizes collective and individual health.

Reexamining Living Arrangements with Parents​

​ Another critical change involves reexamining living arrangements. As children grow and
begin to establish their independence, families often reassess their living situations. The patient
might find herself contemplating the dynamics of living with her parents and how this
arrangement affects her family's emotional and financial stability. Discussions may arise about
whether to continue living together or whether some family members should move out to create
space for the emerging independence of adult children. This reassessment can lead to
negotiations about boundaries, responsibilities, and the overall family structure, which can
significantly influence family relationships.

Adjusting to Own Work Situations​

​ Adjusting to individual work situations is also a prominent aspect of this life cycle stage.
As children launch into their careers or higher education, family members may need to
accommodate varying schedules and demands on their time. The patient may experience shifts
in her work-life balance as she navigates her professional responsibilities alongside her family
obligations. This might involve discussions about flexible work arrangements, the need for
additional support, or the pursuit of new career opportunities to better align with the evolving
family structure. These adjustments not only impact the patient’s sense of self but also influence
how the family unit functions as a whole, promoting a greater understanding of each member's
individual aspirations and challenges.

Second Order Changes in the Family Life Cycle: Launching Children

During the family life cycle stage of launching children, the patient and her family
undergo significant second-order changes that profoundly affect their relationships and
dynamics.

Reevaluation of Family Roles and Identity​

​ One of the most notable changes is the reevaluation of family roles and identity. As
children transition into adulthood, the traditional roles within the family often shift. The patient
may find herself rethinking her position in the family hierarchy, especially as her parents age and
her siblings become more independent. This can lead to a reassessment of responsibilities, as
the patient might take on a more supportive role, guiding her younger siblings or helping her
parents navigate their health concerns. Additionally, this stage encourages family members to
redefine their identities beyond the parental and child roles, fostering a sense of individualism
while maintaining family cohesion. This reevaluation can lead to richer, more fulfilling
relationships as each member begins to see one another as individuals rather than just family
roles.

Development of Adult-to-Adult Relationships​

​ Another critical aspect of this life stage is the development of adult-to-adult relationships
within the family. As children reach adulthood, the dynamics shift from a parent-child relationship
to one that is more equal and reciprocal. The patient may experience a newfound camaraderie
with her parents, characterized by mutual respect and open communication. This transformation
allows for more honest discussions about life choices, values, and experiences, facilitating a
deeper understanding among family members. For the patient, this means not only sharing her
own life challenges and successes but also being able to seek guidance from her parents as
they navigate their own journeys. This evolution toward adult relationships encourages
collaboration and support, ultimately strengthening familial bonds as each member learns to
appreciate the unique contributions of others.

FAMILY ILLNESS TRAJECTORY

A.A.A is currently in Stage III: Major Therapeutic Efforts of the Family Illness Trajectory,
necessitating significant medical intervention due to her admission to the hospital and ongoing
treatment. This stage is characterized by intensive therapeutic actions aimed at managing her
medical condition, while the family adapts to the demands and challenges that arise during this
time.

At present, A.A.A is hospitalized and under careful observation to monitor her progress
and improve her condition. Comprehensive laboratory tests have been conducted, and
appropriate medications have been administered to address her health needs. Given her history
of Non-Hodgkin’s lymphoma, which has since resolved, her admission is crucial, as this history
places her at an increased risk for complications. Furthermore, her employment in the Renal
Unit, where she regularly interacts with immunocompromised patients, highlights the need for
vigilant monitoring and tailored care.
 In this stage, A.A.A and her family are engaged in substantial therapeutic efforts, which
include not only medical interventions but also emotional support and education about her
condition. The family is likely navigating the complexities of her illness together, fostering open
communication and collaboration to ensure a supportive environment conducive to her recovery.

SMILKSTEIN CYCLE OF FAMILY FUNCTION

Based on the provided Smilkstein Cycle of Family Function framework, A.A.A,.’s family is
now in Equilibrium. Previously, the family may have faced stress due to the uncertainty of her
diagnosis and concerns about her health. With a diagnosis and treatment plan in place, and her
being admitted inthe hospital, some of these immediate stressors are alleviated. The family can
now focus on long-term health management rather than emergency or crisis management,
which is key to maintaining equilibrium.
PFC MATRIX

COMPONENTS PATIENT-CENTERED MATRIX

DATA GATHERING ●​ Biomedical History: Female, 26 years old, with

complaints of dyspnea, cough, coryza, headache
●​ PE: BP: 110/70 mmHg, Temp: 36.4 C, HR: 110 bpm, O2
sat: 99% at RA, RR: 26 cpm, Ht: 149.9 cm, Wt: 70 kg,
BMI: 31.2 kg/m2 (class i obesity) ; (+) hyperemic
tonsillar pillars, (+) rales on left lower lung field, (+)
tachycardia, (+)KPS, 3/10
●​ Psychosocial: Well supported by her family, friends,
partner during her illness.

ANALYSIS ●​ (+) hyperemic tonsillar pillars

●​ (+) rales on left lower lung field
●​ (+) tachycardia
●​ (+)KPS, 3/10

ASSESSMENT COMMUNITY ACQUIRED PNEUMONIA-LOW RISK

MANAGEMENT ●​ Prescribe the following medications to the patient:

●​ Piperacillin-tazobactam 4.5g IVTT q8
●​ Acetylcysteine 600mg tab PO BID
●​ Levocetirizine + montelukast (zykast) 5/10 mg tab OD
HS
●​ Nafarin-A 1 tab PO TID RTC
●​ Clarithromycin 500mg tab PO OD
●​ Duavent 1 neb q12

COMPONENTS FAMILY-CENTERED MATRIX

DATA GATHERING ●​ Breadwinner: A.A (Index Patient), M.A (Patient’s sister),

Caregiver: F.B. and E.A. (Patient’s parents)
●​ Family Structure: Nuclear Family
●​ Family Genogram: Breast Cancer and Non-Hodgkin’s
Lymphoma
●​ Family Life Cycle: Families with Launching Children

ANALYSIS ●​ Family Map: Functional

●​ APGAR: Moderately Dysfunctional
●​ Family Illness Trajectory: Major Therapeutic Efforts
(Stage 3)
ASSESSMENT ●​ Smilkstein’s Cycle: Family in Equilibrium

MANAGEMENT ●​ Health education

●​ Family Planning
●​ Educate family on the importance of diagnostic and
treatment adherence
●​ Wellness plan for each member
●​ Educate on the importance of support for the patient’s
needs

COMPONENTS COMMUNITY-CENTERED MATRIX

DATA GATHERING SCREEM

●​ Resource: Social, Cultural, Religious, Educational,
Economic, Medical
●​ Pathology: Social, Religious, Educational, Economic,
Medical
Ecomap:
●​ Able to benefit from Philhealth and CHHM ABL for
medical expenses
●​ Able to benefit from PCSO for additional medical
expenses
●​ Able to receive support from friends and family from
their insurance company

ANALYSIS Readily available access to organizations

ASSESSMENT Well-established extra-familial connections

MANAGEMENT ●​ Advised to participate in religious groups for spiritual

support and counseling
●​ Encourage for active member of Philhealth, SSS, and
PAG-IBIG for monthly contribution
 FAMILY DIAGNOSIS

Medical Diagnosis COMMUNITY ACQUIRED PNEUMONIA- LOW RISK

Family Type NUCLEAR TYPE- DEMOCRATIC PARENTING STYLE

Social Class MIDDLE CLASS

Stage in Life Cycle FAMILY WITH LAUNCHING CHILDREN

Family APGAR MODERATE DYSFUNCTIONAL

Family SCREEM ADEQUATE FAMILY RESOURCES

Family Illness Trajectory STAGE III MAJOR THERAPEUTIC EFFORTS

Smilkstein Life Cycle FAMILY IN FUNCTIONAL EQUILIBRIUM