Family Case Study Presenting Problem:

Family Case Study PRESENTING PROBLEM: The patient, Herbert Schelley, is a 66-year-old Caucasian male, referred for home care evaluation due to polypharmacy and multiple medical conditions with poor control. Patient was recently hospitalized on the medical-surgical ward of the local hospital for IV antibiotics surrounding an ongoing case of cellulitis that was worrisome for progression to osteomyelitis. The patient was treated inpatient with a 6 day course of antibiotics. During his hospitalization it was noted that the patient had a significant knowledge deficit surrounding his multiple disease states.

His home situation was unclear. For this reason, and to facilitate disease and medication management, a family home study was ordered. PAST MEDICAL HISTORY: The patient's past medical history is significant for the following: Type 2 Diabetes, poorly controlled. Hypertension, poorly controlled as evidenced by 5 day blood pressure average in the hospital of 188/96 Obesity as evidenced by a height of 6 feet 2 inches and a weight of 316 pounds resulting in a BMI of 40.6 Cellulitis of the left lower extremity, currently being treated with Cephalexin 1000 mg QID for 10 days.

Microalbuminuria Hyperlipidemia Home visit was accomplished on 2 April 2005. The visit was accomplished in the midmorning and present at the visit were the patient, Mr. Schelley, his wife of 40 years, Mrs. Annette Schelley, and their 38-year-old son, Thomas, who lives in the household with Mr. And Mrs. Schelley. The family lives in a 1200 square foot ranch house in a middle class neighborhood. It is a two bedroom, one bathroom house purchased by the Schelley's five years ago when Mr. Schelley took early retirement from a local manufacturing plant.

Thomas returned home about a year ago after separating from his wife. He is currently unemployed and living in the extra bedroom. His presence in the house is a source of significant stress and the cause of many arguments between Mr. And Mrs. Schelley. This write-up was done from information obtained over the course of two home visits.

S: The patient is a 66-year-old Caucasian male referred to the Home Health Care program for management of polypharmacy issues as well as evaluation surrounding his apparent lack of education on the management of his diabetes and his hypertension. The patient was recently hospitalized for 6 days for intravenous antibiotics to treat a cellulitis of the left lower extremity. Past Medical history is significant for poorly controlled Type II Diabetes, Hypertension, Hyperlipidemia, and Cellulitis of the left lower extremity, obesity, and microalbuminuria.

Past Surgical History is significant for right inguinal hernia repair in 1998 with no sequellae. Patient also underwent debridement of a wound on the left lower extremity during his recent hospitalization. The wound is currently healing and only requires dry dressing. Last funduscopic exam was greater than one year ago. Review of systems: Patient describes increased fatigue over the last few months. His appetite is good.

He denies any other siginificant physical findings Current medications: Metformin 500 mg TID Lisinopril 20 mg QD Atenolol 100 mg QD Lovastatin 40 mg QD Cephalexin 500 mg QID x 10 days Multivitamin QD Vitamin C 3000 mg QD Chondroitin/Glucosamine 200 mg po QD. Acetaminophen/Oxycodone 325/5 po q 6 hours prn pain Social History: The patient is married x 40 years to his wife, Annette. They live together here in town. The patient is a retired machinist, having taken early retirement five years ago when his health began to deteriorate.

He quit smoking 15 years ago and has a 20 pack year history. He currently has no hobbies other than some woodwork which he does around the house. He states he is a social drinker, with alcohol intake of less than 3 drinks per week. He denies prior history of alcohol addiction or abuse. The patient denies the use of illicit drugs.

He has three children, two daughters - Sarah and Denies who are 35-year-old twins who are married and live in the local area and one son, Thomas, 38, who is separated, unemployed and living in the home with the patient and his wife. Objective Data: The patient is an overweight Caucasian male in no apparent distress. He is somewhat disheveled and dressed in an oversized sweatshirt and sweat pants, interviewed in his living room in the presence of his wife and son. His BP is 180/92, pulse is 88, and respirations are 18.

The patient is alert and oriented. His speech is clear and coherent. He is a fair historian but appears to have a limited fund of knowledge regarding his medications and his disease processes. His wife is able to offer some collateral information but is not able to give much more information than the patient does. HEENT: Normocephalic, atraumatic. Normal facies. Oropharynx is unremarkable. Dentition is poor; patient has a partial plate which he is not wearing at the time of the exam. No cervical adenopathy or thyromegally is noted.

Funduscopic difficult to assess secondary to pupillary constriction. PERRL, EOMI, no lid lag or edema. Otherwise exam is unremarkable. Chest: CTA over all lung fields, although breath sounds are slightly distant. CV: RRR without murmurs or rubs. No carotid bruit is ausculated. No JVD. Abdomen: Obese. Bowel sounds within normal limits all four quadrants. No guarding, rebound or tenderness. No organomegally although exam is limited by abdominal girth. There is a well healed surgical scar in the right lower inguinal area. There is evidence of an umbilical hernia.

Extremities: 2x2 cm eschar located on medial aspect of left lower extremity. Dressing is in place, clean and dry. There is decreased sensation to vibration and pinprick bilaterally both lower extremities. Feet are warm, skin is pink and dry. Dorsalis pedis and tibial pulses 2+ bilaterally. Great toenails on both feet are thickened and hyperkeratotic. There is evidence of scale on the plantar surface of both feet. Otherwise exam within normal limits. Neuro: Cranial nerves II-XII grossly intact. Upper and lower extremity strengths within normal limits and equal bilaterally.

Gait is unremarkable. Rhomberg is negative. Babinski is negative. Deep tendon reflexes are 2+ and brisk upper and lower extremity. No tremor is noted. GU/Rectal: Deferred. Mental Status Exam: Patient is alert and oriented x 3. Affect is appropriate to mood and thought content. Mood is friendly, slightly sad. Thought content and thought processes appear to be intact. Patient denies current suicidal, homicidal or physically endangering ideation.

Assessment" Diabetes, Type II, poorly controlled Cellulitis, left lower extremity (resolving) Hypertension, poorly controlled Hyperlipidemia Microalbuminuria Mobid Obesity Onychomycosis, bilateral great toes Tinea pedis Bilateral lower extremity neuropathy, likely secondary to Diabetes. Knowledge deficit related to dietary management of his medical conditions (diabetes, hyperlipidemia) Knowledge deficit related to medical management of his medical conditions (diabetic monitoring, exercise and it's affect of his disease states, weight loss) Plan: Continue current outpatient medications as currently prescribed. Referral to primary care physician for medication for onychomycosis and tinea pedis.

Referral to general surgery for evaluation of umbilical hernia Referral to ophthalmology for annual eye exam Provide education surrounding management surrounding the patient's diabetes i.e. setting testing goals, setting testing frequency. Provide education surrounding management of patient's blood pressure issues, i.e. exercise, dietary management, compliance to medication management, home monitoring Provide education surrounding dietary management of multiple disease issues, i.e. diabetic and weight loss diets Provide Education surrounding possible adverse effects of poor control of diabetes.

Calgary Family Assessment Model (CFAM) the CFAM is a method of providing a thorough family assessment in a healthcare setting. The CFAM has three major categories: 1) the structural dimension of family life, 2) the developmental dimension of the family life and 3) the functional dimension of the family life. Each of these separate categories has subcategories which the clinician can use to evaluate the family situation. Each category may not apply to each family, and it is the role of the clinician to pick which sections are the most appropriate.

Section 1 - the Structural dimension. This dimension deals with the internal and external structure of the family life. Internal structure contains issues like the composition of the family, gender, rank order in the family, subsystems within the family and boundaries. The external structure contains the extended family and any larger systems which may exist within the family unit. The structural dimension will also be examined with the context of race, ethnicity, social class, religion and environmental factors. Section 2 - the developmental dimension deals with the family life cycle.

This dimension of the assessment helps the clinician understand how the balance exists between stability and change in the family. It addresses processes over the family's life span which is associated with the growth of the family. Some of these processes can be things like chronic illness of a family member, work issues, relocation, etc. It is also important to remember that subsets in the developmental dimension may also be psychological in nature, such as intimacy and grief issues.

Section 3 - the functional dimension relates to instrumental and expressive functioning within the family. Instrumental functioning is specific for the routine activities of daily living such as preparing meals, eating, sleeping, hygiene and attendance to health needs. Expressive functioning is related to communication such as emotional, verbal, and nonverbal communication, problem solving and roles within the family. Beliefs within the family are also a part of expressive functioning. For the purpose of the Calgary Family Assessment Model, a family is defined as who they say they are.

It is very important that the clinician performing the assessment not assign their own beliefs upon what he or she believes a family is, and take into account what the patient feels about family as to the patient is may mean not only the people who actually live within the household but can also address past, present and future emotional attachments. Calgary Family Intervention Model: The immediate family is composed of Mr. Herbert Schelley (the patient), Mrs. Annette Schelley (his wife), and their son Thomas Schelley.

The extended family consists of the Schelley's two married daughters, their husbands and their children (the patient's grandchildren). Mr. Schelley describes his family as close and loving, and states that the extended family of often over to the house for dinner and visited him regularly in the hospital. Mr. Schelley and Thomas admit to some tensions between them in the past six months surrounding Thomas's lack of employment and the fact that he continues to live in the family home. Mr.

Schelley and Thomas still describe their relationship as close, and Thomas appears to demonstrate the appropriate amount of concern for his father's medical condition. Mrs. Schelley and Thomas endorse that Mr. Schelley's illness and recent hospitalization has caused a great deal of anxiety and concern in the immediate and extended family. Mrs. Schelley reports feeling somewhat overwhelmed at the thought of providing nutritious and appropriate meals for Mr. Schelley, who describes himself as "a meat and potatoes man, I am fond of my sweets." Mrs.

Schelley admits that she does not really know what she should cook for her husband, and has little or no knowledge about portion control. Mrs. Schelley reports that she knows that many of the things she buys or prepares for her husband are not good for his health, but does not feel like she has the right to tell him what to eat or how to manage his diseases. The gender expectations in the Schelley household are "typical," in that Mr. Schelley was always the monetary provider and Mrs.

Schelley was a stay-at-home wife and mother. Both Mr. Schelley and Mrs. Schelley admit they have been somewhat at a loss for activities since Mr. Schelley's retirement. They have few friends outside the home and belong to no social clubs or religious organizations. It is noteworthy that Mr. Schelley has gained 50 lbs since his retirement five years ago. Mr. Schelley is the oldest member of the family at 66. Mrs. Schelley is 64, Thomas is 38 and the twin daughters are 35. There are several subsystems within the family. Mr. And Mrs.

Schelley, the daughters and their husbands consist of husband and wife subsystems, while the Schelleys and Thomas consist of another subsystem. While the twin daughters are also involved in their parents' life, they are not so intimately involved in the day-to-day happenings within this household. A parent and child subsystem exists between Thomas and Mr. Schelley. This subsystem is the source of some significant disagreements within the household. Mr. Schelley does not approve of the fact that Thomas has left his wife and is not currently working. Mr.

Schelley also feels that Thomas drinks too much alcohol. Thomas admits to the use of approximately one six pack of beer per day. Mrs. Schelley admits that she tries to stay out of their arguments. They all deny any family violence, and report that the disagreements usually end with Thomas leaving the house for several hours. Mr.

Schelley and Thomas both report they usually only have these disagreements once or twice per month, but admit there is rarely any closure and that they seem to fight over and over about the same things. The reporting of these arguments does not appear to cause Mr. Schelley or Thomas any siginificant distress, but Mrs. Schelley does admit that their disagreements are often very upsetting to her. It is noteworthy that when this came up in conversation, both Mr. Schelley and Thomas seemed both genuinely surprised and concerned at Mrs.

Schelley's report of distress. The husband and wife subsystem and the subsystem the Schelley's appear to share with their adult daughters and the daughter's families appear to have clear boundaries, although with permeable borders which allow flexibility. The boundary that Mr.

Schelley shares with Thomas appears to be more dynamic in nature, in that Thomas is attempting to define himself as a grown man in relationship to his father, the dichotomy being that he is trying to do so while living under his father's roof with no visible means of support. Mrs. Schelley's boundaries with the.