RESHMA.HC & SHAHNAZ BEEGUM 7th SEMESTER ,MBBS

CLINICO -SOCIAL CASE STUDYPOST-NATAL CASE

NAME : SUJA AGE : 26yrs SEX : female HOUSE NO : TC 2058 WARD NO : 9

GENERAL INFORMATION

FAMILY PROFILE

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

TOTAL FAMILY INCOME FROM ALL SOURCE : 18000/-

PER CAPITA INCOME : 18000/6 = 3000 Economic status – upper middle class

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.

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.

A) Housing Owned Pucca house No. of living rooms: 2 Location: suitable land

ENVIRONMENT

Kitchen,bathroom and sanitary latrin present Adequate ventilation Adequate natural lighting Artificial lighting source : flurescent lamps General cleanliness of rooms - inadequate over crowding present

kitchen: a) windows : adequate b) smoke outlet: Absent c) Floor : Pucca d) kitchen : separate e) fuel used : LPG

Source of water supply : well water…using boiled water….<15ft from latrin…unprotected

Thrown near the house

REFUSE DISPOSAL

Water logging in nearby areas & open drains

Cloths are put on the ground near to waste

Positive container present

Domestic animal : one dog Cattle shed: absent

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

REFUSE DISPOSAL:- Should be disposed off properly. Correction of Water loggingPERSONEL HYGEINE Proper cutting of nails Use properly cleaned cloths only

HISTORY OF POSTNATAL MOTHER

Bathing habits- daily Nails-unclean brushing teeth- daily (once) Hand washing practices: after defecation ,

before & after taking meals

PERSONAL HYGIENE

Menarche at 12yrs Regular periods No h/o dysmenorrhea/menorrhagia

MENSTRUAL HISTORY

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

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

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

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

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

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

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

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 .

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

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

Exclusive breast feeding upto 6 months Supplimentary feeding should start at 6

months Adequately immunise for age

ADVICE FOR BABY CARE

EXAMINATION OF MOTHER

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

Afebrile Pulse -80/ min ,regular , Adequate in

volume BP not recorded Repiratory rate – 17/min , regular

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

EXAMINATION OF INFANT

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

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

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

Head circumference = 36cm (Normal for age- 35-38cm)

Chest circumference = 33cm

Mile Stones of development (for that specific age): Achieved

Personal Hygiene: adequate No cases of diarrhoea/pneumonia

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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