CLINICO SOCIAL CASE STUDY
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Transcript of CLINICO SOCIAL CASE STUDY
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RESHMA.HC & SHAHNAZ BEEGUM 7th SEMESTER ,MBBS
CLINICO -SOCIAL CASE STUDYPOST-NATAL CASE
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NAME : SUJA AGE : 26yrs SEX : female HOUSE NO : TC 2058 WARD NO : 9
GENERAL INFORMATION
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FAMILY PROFILE
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TYPE OF FAMILY : extended FAMILY COMPOSITION
FAMILY HISTORY
NAME RELATION WITH HEAD
AGE SEX
MARITAL STATUS(yes/no)
Edn
Occn.
Inc. (/month)
Immn.
Health problems
1.Sudhevan2.Vasantha 3.Suja4.Manikutan 5.Vaishnav 6.Vaishnavi
…….wifeDaughterSon-in-lawGrand sonGrand -daughter
6052263261 mnth
M FFMMF
YesYesYesYesNoNo
SSLCSSLC+2SSLCUKG……..
Coolie……..………Coolie............……….
8000/-0010000/-00
UnknownUnknownUnknownUnknownAdequateadequate
NoneDiabeticNoneNoneNoneNone
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TOTAL FAMILY INCOME FROM ALL SOURCE : 18000/-
PER CAPITA INCOME : 18000/6 = 3000 Economic status – upper middle class
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MEDICAL HISTORY OF FAMILY
Suja’s mother is suffering from DM for 10 yrs Diabetic foot present Patient developed increased thirst,
dryness of throat & numbness of extremities 10 yrs back following which she underwent blood tests & DM detected
She is on oral hypoglycemics since then.
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Her sugar level is not under control Oral tablets changed to insulin Treatment is taken from PHC at Pangappara No services from nearest subcenter and
anganwadi suja’s father has undergone TURP 6 months
ago at MEDICAL COLLEGE,TRIVANDRUM Due to expiry of his RSBY card,he had to pay
cash for it.
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A) Housing Owned Pucca house No. of living rooms: 2 Location: suitable land
ENVIRONMENT
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Kitchen,bathroom and sanitary latrin present Adequate ventilation Adequate natural lighting Artificial lighting source : flurescent lamps General cleanliness of rooms - inadequate over crowding present
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kitchen: a) windows : adequate b) smoke outlet: Absent c) Floor : Pucca d) kitchen : separate e) fuel used : LPG
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Source of water supply : well water…using boiled water….<15ft from latrin…unprotected
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Thrown near the house
REFUSE DISPOSAL
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Water logging in nearby areas & open drains
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Cloths are put on the ground near to waste
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Positive container present
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Domestic animal : one dog Cattle shed: absent
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REMEDIES
Medical Treatment for the current medical
conditions of family members.LIVING CONDITIONS . General cleanliness of rooms should be
ensured. source of clean water should be ensured. storage utensils should be kept covered
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REFUSE DISPOSAL:- Should be disposed off properly. Correction of Water loggingPERSONEL HYGEINE Proper cutting of nails Use properly cleaned cloths only
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HISTORY OF POSTNATAL MOTHER
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Bathing habits- daily Nails-unclean brushing teeth- daily (once) Hand washing practices: after defecation ,
before & after taking meals
PERSONAL HYGIENE
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Menarche at 12yrs Regular periods No h/o dysmenorrhea/menorrhagia
MENSTRUAL HISTORY
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AGE OF MARRIAGE : Husband – 26yrs Wife – 20yrs Became pregnant 6 months after
marriage First delivery at 21yrs Spacing by using condoms for 5yrs No h/o infertility treatment
MARITAL HISTORY
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First pregnancy at 21yrs Iron & folic acid taken Two doses of TT taken No h/o GDM/GHTN No h/o of abortions/still birth/MTP
PAST OBSTETRIC HISTORY
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LMP : 7/8/15 EDC : 15 /04/16 Iron & folic acid taken Two doses of TT taken 5 times she consulted her doctor during
pregnancy for regular check up No h/o of antenatal complications
ANTE-NATAL HISTORY
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Full term normal vaginal delivery coducted at SRI-RAMAKRISHNAMISSION HOSPITAL,Sasthamangalam on 07TH APRIL 2016.
About 10000/- is spent for pregnancy care
System of treatment- Medicine. Nature of treatmnt - private
INTRA-NATAL HISTORY
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Birth weight : 3.5gm Baby Cried soon after birth Breast feeding started within 1hr Breast feeding adequate Lactogen is also given Immunization card present Adequately immunized for age
POST NATAL HISTORY
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Aware of family planning Condoms used for 4 yrs aftr first delivery Family planning advice was given by doctor As per his advice tubectomy was done after
2nd delivery.
H/O FAMILY PLANNING
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DIETARY HABITTIME FOOD ITEM AMOUNT CALORIES
IN KCalPROTEIN IN GRAMS
7 am TeaBiscuits
1 cup2
70kcal66.8
24.8
8 am AppamPayaru curry
32 table spoon
294100
5.047.2
12 30 pm RiceFish fryCarrot thoran
3 cup2 pieces1 table spoon
3501007.2
4.8200.135
4 00 pm TeaBiscuits
1 cup2
41.566.8
1.64.8
8 00 pm RiceFish fryCarrot thoran
1 cup2 pieces1 table spoon
3501007.2
4.8200.135
TOTAL …………….. …………… 1645.7 61.25
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Energy requirement = 2500 kcal/day Total energy consumed =
1645.7kcal/day Calorie deficit of 854kcal/day
Protein requirement = 1gm * body wt.+19 = 94gm/day
Total protein consumed = 61.25gm/day Inadeuate .
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Family advised to increase the food quantity to coverup the food deficit.
Advise to take protien and calcium rich food such as milk and grams.
Advice to take fruits and leafy vegetables. Advice for postnatal exercises
CORRECTION OF DIETARY CONSUMPTION
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DIETARY PLANTIME FOOD ITEM AMOUNT CALORIES IN
KCalPROTEIN IN GRAMS
7 am TeaBanana
1 cup2
70200
22
8 am AppamPayaru curry
32 table spoon
294100
5.047.2
10 am MilkEgg
1cup1
14080
66
12 30 pm RiceFish fryCaSambar
2cup2 pieces1 table spoon1cup
3501007.250
4.8200.135 2.5
1;30 pm Mango 1 148 1.2
4 00 pm TeaVada
1 cup3
70150
23
7 00 pm RiceFish fryDrumstick leaves -thoranSambar Pappadam
2cup2 pieces200gm
1 cup2
1751001845040
82013.4
2.51
10.oopm Milk 1 cup 140 6TOTAL …………….. …………… 2525.5 125.24
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Exclusive breast feeding upto 6 months Supplimentary feeding should start at 6
months Adequately immunise for age
ADVICE FOR BABY CARE
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EXAMINATION OF MOTHER
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Coperative,consious and well oriented to surroundings Ht – 160cm wt – 75kg Moderately bulit and nourished Pallor- absent Icterus- absent Cyanosis- absent No clubbing No pedal edema No thyroid enlargement/neck swellings
GENERAL EXAMINATION
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Afebrile Pulse -80/ min ,regular , Adequate in
volume BP not recorded Repiratory rate – 17/min , regular
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CVS – s1,s2 heard, no murmurs Resp – air entry bilaterally equal,no
rhonchi/crepitation CNS – HMF/SNS/MNS/CN appears to be
normal GIT – No abdominal tenderness/distension
SYSTEMIC EXAMINATION
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EXAMINATION OF INFANT
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Active and playful Moderately bulit and nourished Pallor- absent Icterus- absent Cyanosis- absent No clubbing No pedal edema No thyroid enlargement/neck swellings
GENERAL EXAMINATION
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CVS – s1,s2 heard, no murmurs Resp – air entry bilaterally equal,no
rhonchi/crepitation CNS – appears to be normal GIT – No abdominal tenderness/distension
SYSTEMIC EXAMINATION
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ANTHROPOMETRIC ASSESSMENT
WEIGHT Weight of child=5.5kg Weight for age= (Age in months+9)/ 2 = (1+9)/2 =5kgHEIGHT
Height of child= 55 cm
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Head circumference = 36cm (Normal for age- 35-38cm)
Chest circumference = 33cm
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Mile Stones of development (for that specific age): Achieved
Personal Hygiene: adequate No cases of diarrhoea/pneumonia
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VACCINES DATEBCG OPV-0Hepatitis B-0
07/04/16
DPT-1(6 weeks)OPV-1Hepatitis B
21/05/16
IMMUNISATION HISTORY
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THANK YOU