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Clinico-social case

Presentation · July 2022

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Deepanshi Saxena Dhiraj Kumar Srivastava

S.N. Medical College, Agra U.P. Rural Institute of Medical Sciences & Research
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Clinico-social case
Moderated by: Presented by:
Dr. Dhiraj Kr. Srivastava Dr. Deepanshi Saxena
Associate Professor PG JR 3rd year

1
 Outline
• Demographic profile
• Chief complains
• History of presenting illness
• Past history
• Present Treatment
• Personal history
• Family history
• Dietary history
• Socio-economic status
• Housing condition and Environmental
condition
• General and Systemic examination
Differential diagnosis
• Web of causation
• Knowledge, Attitude and Practice
• Advice
2
 Demographic Profile
• Name – Mrs. Shanti Devi Dubey
• Age – 75 yrs/ Female
• Residence – Ujhiyaini
• Education – 5th class
• Occupation –Housewife
• Marital Status – Widow
• Religion/Caste - Hindu/ Brahmin
• Family Type- Three Generation Family
• Nearest Health Facility (Govt)- U.P.U.M.S. Saifai, Etawah
3
 Details of Family Member
S.N. Name Age Sex Marital Education Relation with Occupation Monthly
(Years) Status (class Head of family Income
passed) (in ₹)
th
1 Mrs. Shanti Devi 75 F Widow 5 Head Housewife -
Dubey
(Index case)
th
2 Mr. Hridesh 50 M Unmarried 10 Son (Younger) Security guard 6,000
Dubey
th
3 Mrs. Saroj Dubey 40 F Married 5 Daughter- in-law Housewife -
(of elder son)
4 Pankaj 18 M Unmarried BSc Grandson Student -
th
5 Soni 16 F Unmarried 12 Grand daughter Student -
th
6 Gauri 14 F Unmarried 10 Grand daughter Student -
th
7 Shivani 12 F Unmarried 7 Grand daughter Student -
rd
8 Tripti 7 F Unmarried 3 Grand daughter Student -
9 Riyansh 1 and 4 M Unmarried --- Grandson ---- -
months
4
 Pedigree Chart
Mrs. Shanti
Devi Dubey
Late. Mr. Sooraj Dubey

Mrs. Kusuma Mr. Awadesh Dubey

Mr. Ravindra (Resides in Gujrat) Mr. Hridesh Dubey
devi
Tiwari

Married

5
Chief Complaints
1. Generalised weakness for one and half month
2. On and off Headache for one months
3. Watery eyes for 15-20 days
[as on 11/11/2021]

6
History Of Present Illness
• Generalised Weakness for one and half months

Onset Gradual
Progression Progressive
Duration For one and half months
Variation No diurnal variation

7
History Of Present Illness
• Associated symptoms- dizziness, sometimes on and off headache
• Not associated with anxiety, chest pain and palpitation, breathlessness
• Not associated with malena or hemoptysis, nausea, vomiting
• No fever, symptoms of UTI (change in frequency of micturition, itching, lower
abdomen pain), sore throat, sputum, cold, cough
• No diarrhea/ constipation, anorexia, weight loss
• Aggravating factor- None
• Relieving factors- self medication (pcm), rest, not relieved completely
• Consulted private practitioner, not relieved completely

8
Investigations on 9/10/2021

9
Prescription

10
History Of Present Illness
• On and off Headache for one months

Site Whole head

Onset Gradual
Duration One months
Nature Dull aching
Progression Progressive
Radiation Not radiated
Variation Mostly in morning

11
History Of Present Illness
Aggravating factor None
Associated symptoms Blurred visison, sometimes with generalised
weakness
No nausea/ vomiting, no fever/ diarrhea/
constipation/ sore throat/ cold/ cough,
unconsciousness, seizures, dizziness

Relieving factors Self medication (Saridon, diclofenac from the

medical store), Tab. Telmikind AM (prescribed
by Private Practitioner)

Not consulted any doctor

12
History Of Present Illness
• Watery eyes for 15-20 days

Site Both eyes

Onset Gradual
Duration One month
Progression Progressive
Variation No variation

13
 History Of Present Illness
Aggravating factor None
Associated symptoms Blurring of vision, dull pricking
sensation (no itching, no redness)

Relieving factor Washing eyes, rest but not relieved

completely

Used to wear specs but lost it around 1 months back

Consulted the private practitioner, eyedrops prescribed but not relieved (no
documents found)

14
 Past History

• Diagnosed as Case of Hypertension two years back by private

practitioner (Investigations / Prescription: not documented)
• Medication : tab Telmikind AM od
• Irregular medication
• Took when dizziness and weakness or headache

15
Past History (Contd.)
• Cataract operation in both eyes
• First operation (Farrukhabad, 2001) and Second operation (Etawah
District Hospital, 2003)
• History of fall from stairs at home 2-3 years back, consulted private
practitioner but hand joints dislocated
• Unaware of previous history of Tuberculosis, Jaundice, Asthma,
Diabetes, Angina, Stroke, Paraesthesia or any other chronic disease
• No history of prolonged immobilisation

16
Present treatment history

Treatment from UPUMS, Saifai

OPD Slip [8/12/2021]
• Prescribed for glasses
• Maintain eye hygiene

17
Present treatment history
Treatment from UPUMS, Saifai
OPD Slip [10/12/2021]
• BP: 150/90 mm Hg
• Prescribed
Tb Amlodipine 5mg bd
Tb Atenolol 25 mg od
Cap Omez bd
Tb B complex
Tb Albendazole
18
Present treatment history

Treatment from UPUMS, Saifai

OPD Slip [10/12/2021]
• Trichiasis: lashes removed

19
 JNC-8 Criteria For Hypertension

Blood Systolic BP Diastolic BP BP=140/80 mm Hg

Pressure (mm Hg) (mm Hg) as measured on first
Classification Normal visit
Normal <120 and <80
Pre- 120-139 or 80-90
hypertension
Hypertension 140-159 or 90-100
Stage- I
Hypertension ≥160 or ≥100
Stage -II

https://www.aafp.org/afp/2014/1001/p503.html 20
 Rule of Halves
Index case

1.
2.
3.
5. 7. 8.
4.
6. 9. 1. The whole community
2. Normotensive subjects
3. Hypertensive subjects
4. Undiagnosed hypertension
5. Diagnosed hypertension
6. Diagnosed but untreated
7. Diagnosed and treated
8. Inadequately treated
https://www.cdc.gov/bloodpressure/index.htm
9. Adequately treated21
Investigations
[10/12/2021]

22
23
24
25
 Present treatment history

Treatment from UPUMS, Saifai

OPD Slip [15/12/2021], follow-up
with reports
• BP: 130/80 mm Hg
• Diagnosed: Typhoid

26
15/12/2021
• Glasses checked again
ADVICE
• Investigations could have been done
RBS
LFT
KFT
Lipid profile
Serum electrolytes
ECG
ECHO

27
Personal History
Physical activity Sedentary lifestyle
Sleep: 5-6 hours at night and 1-2 hours
during day
Diet Vegetarian
Personal hygiene Bathes daily
Keeps hair clean
Nails untrimmed
Clean clothing
Sanitation Toilet (self financed)
Addictions (Tobacco/ pan/ bidi) None
COVID-19 Vaccination Vaccinated for both doses
(COVISHIELD)
28
 PERSONAL HYGIENE
Dressings Improper/ proper Score Source: Community Medicine
Unclean/ Clean 1 practical Guide 2nd edition,
Kusumlata Gaur
Un-Ironed/ ironed 0
Skin Unclean/ Clean 1
Diseased/ non diseased 0
Hair Unclean/ Clean 1
With louse infestation/ 0
without louse
infestation
Uncombed/ combed 1
Scoring
Eyes Unclean/ Clean 1
0 to 5 =
Ears Unclean/ Clean 1 Poor
Face Unclean/ Clean 1 6 To 10 = Fair
More than 10= Good
Teeth Unbrushed/ Brushed 1
Here total score is 9, so patients
Diseased/ Non Diseased 0 personal hygiene comes under Fair
category
Nails Unclean/ Clean 1
Footwear No / Yes 0
Total 9 29
 Obstetric and Gynaecologic History

Menarche 12-13 yrs

Age at marriage 15 yrs
Total number of children 3
Full Term pregnancies 3
Normally delivered at home by trained Dai
Menopause (Age) 49-50 yrs

30
 Family History

• H/o throat cancer in patient’s husband , Died 7-8 years ago, (prescriptions
lost)
• Unaware of family history of Tuberculosis, Diabetes mellitus, Hypertension,
Stroke and genetic disease in the family (parents / husband)

31
 Income Details
Direct income Amount Indirect Income Per annum Amount
(Rs) (5 Bigha farm) (Rs)
Mr. Awdhesh = 11,500 per Wheat 15 Quintal Total expenditure 7,000
(resides outside) month store Total earnings 30,000
2 Quintal sell Net profit 23,000
Mr. Hridesh = 6,000 per Rice 5 Quintal store Total expenditure 5,000
month Total earnings 12,500
Net profit 7,500
Potato 250kg store Total expenditure 2,000
Total earnings 4,500
Net profit 2,500
Total direct income = 17,500 per month Total indirect income 33,000/-
Indirect income Per month 2,750
Total income per month= 20,250
Total family members = 9 Per capita monthly income= 2,250/- Rs
32
 SES: Modified B. G. Prasad Classification
(AICPI up to September 2021)

Socio- Per capita monthly

Socio- income (modified)
economic Per capita monthly income= 2,250/- Rs
economic
classificatio Lower
Class Upper limit
n limit
I Upper 24674 Infinity
Upper
II 12337 24673
Middle
Lower
III 7402 12336
Middle
IV Upper Lower 3701 7401

V Lower 0 3700
Source: https://prasadscaleupdate.weebly.com/real.html

33
 SES: Revised Udai Pareek
Classification

Total score: 21

GRAD CATEGORY SCORE ON

E SCALE
A Upper class Above 43
B Upper middle class 33-42
C Middle class 24-32
D Lower middle class 13-23
E Lower class Below 13

34
 Dietary History (24 Hour Recall, Day 1)
Calorie Protein
Time Food item Quantity Iron (mg) Fat (gm)
(kcal) (gm)
7:30
Tea with cow milk and sugar ½ Glass 58.5 2 0.13 2.6
am

White bread 2 nos (40 g) 100 3.08 - 0.52

12 Roti 2 266.9 8.4 2.1 1.3

pm Aloo-gobhi sabji 1 katori 170 17.8 1.3 9.8
4:30
Tea with cow milk and sugar ½ glass 58.5 2 0.13 2.6
pm
8:30 Daliya 1 135.28 3.1 1.9 0.6
pm Cow Milk 1 glass 167.5 8 0.5 10.3
Sugar 1 tbspoon 60 - - -
Total 1,016.7 44.38 6.06 27.7
Total water intake 2-3 glasses
35
 Dietary History (24 Hour Recall, Day 2)
Calorie Protein
Time Food item Quantity Iron (mg) Fat (mg)
(kcal) (gm)
7:30
Tea with cow milk and sugar ½ Glass 58.5 2 0.13 2.6
am
12 Roti 2 266.9 8.4 2.1 1.3
pm Cow Milk 1 Glass 167.5 8 0.5 10.3
4:30
Tea with cow milk and sugar ½ Glass 58.5 2 0.13 2.6
pm
8 pm Roti 2 266.9 8.4 2.1 1.3
Arhar dal 1 katori 141.9 7.37 0.99 18.81

8:30 Cow milk 1 Glass 167.5 8 0.5 10.3

pm
Sugar 1 tbspoon 60 - - -
Total 1187.7 44.17 6.45 47.21
Total water intake 2-3 glasses
36
Dietary History (24 Hour Recall, Day 3)
Calorie Protein
Time Food item Quantity Iron (mg) Fat (mg)
(kcal) (gm)
7:30
Tea with cow milk and sugar ½ Glass 58.5 2 0.13 2.6
am
12 Rice 2 219.2 7.0 1.8 0.2
pm Arhar Dal 1 katori 141.9 7.37 0.99 18.81
4:30
Tea with cow milk and sugar 1 katori 58.5 2 0.13 2.6
pm
8 pm Roti 2 266.9 8.4 2.1 1.3
Milk ½ glass 83.75 4 0.25 5.15

8:30 Cow milk 1 glass 167.5 8 0.5 10.3

pm
Sugar 1 tbspoon 60 - - -
Total 1056.25 38.77 5.9 40.96
Total water intake 2-3 glasses
37
 Calculation Of Calorie Intake
Calorie requirement Protein Fat Iron
(kcal/day) requirement requirement requirement
(g/kg/day)x body (mg/day) (mg/day)
weight
Sedentary women of 50kgs, 1419 36.3 18 13
>60 yrs body weight* 0.83 × 50 ×1 = 41.5

DAY 1
Total 1016.7 44.38 27.7 6.06
Gap for Index case 402.3 deficient 2.88 excess 9.7 excess 6.94 deficient
DAY 2
Total 1187.7 44.17 47.21 6.45
Gap for Index case 231.1 deficient 2.67 excess 29.21 excess 6.55 deficient
DAY 3
Total 1056.25 38.77 40.96 5.9
Gap for Index case 362.8 deficient 2.73 excess 22.96 excess 7.1 deficient
38
**ICMR- NIN Expert Group on Nutritional Requirements of Indians, Recommended Energy Requirements (RDA), and Estimated Energy Requirements (EAR), 2020.
Dietary History (Food Supplies For October, 2021)
Ration Amount (Approximate)
Cereals Wheat flour 20-25 kg
Rice 5 kg
Pulses Moong Dal 5 kg whole
Urad Dal
Arhar Dal
Masoor Dal
Vegetables Cauliflower 3 kg whole
Carrot
Pea
Tomato
Diary Cow Milk 3kg
Condiments Oil/ Ghee 6kg
Sugar 4kg
Salt 1.5 kg
Masala Varies
Fruits Apples 2 kg whole
Banana
39
 Dietary History by the ration for one month

Food Amount Energy (kcal/g)

Wheat 25 kg 25,000 ×4 =1,00,000
Rice 5 kg 5000 ×4 = 20,000
Pulses 5 kg 5000 × 9 = 45,000
Sugar 4 kg 4000 × 4 =16,000
Milk 9 lts 90,000× 67/100 =60300
Oil/Ghee 6 kg 6000 × 9 =54,000
Actual energy intake in one month =295300/30
= 9843.3

40
 Estimated Average Requirement (EAR)
S.N. Name Energy (kcal/g)
1 Mrs. Shanti Devi Dubey 1419
(Index case)
2 Mr. Hridesh Dubey 2532
3 Mrs. Saroj Dubey 2048
4 Pankaj 2344
5 Soni 2500
6 Gauri 2400
7 Shivani 2060
8 Tripti 1700
9 Riyansh 670
Total energy needed 17,673
Energy deficient 17,673-9843.33 = 7829.67
Energy deficient per person 7829.67 /9 ~ 870
41
**ICMR- NIN Expert Group on Nutritional Requirements of Indians, Recommended Energy Requirements (RDA), and Estimated Energy Requirements (EAR), 2020.
 Details of Nutritive Value Calculation Of Specific
Food Item
Tea
• 1 glass water + 1 glass cow milk + 2 tablespoons white sugar
• 100 ml cow milk = 67 Kcal, 3.2g Protein, 0.2mg Iron, 4.1g fat
• 250 ml cow milk = 167.5 Kcal, 8g protein, 0.5mg,10.3gfat
Iron
• 1 tbsp sugar = 60 Kcal
• 2 tbsp sugar = 60x2= 120 Kcal
• Total Kcal = 167.5 + 120= 234.5 kcal
• ½ glass tea = 234.5/ 4 = 58.5 Kcal, 2g protein, 0.13 mg iron,2.6g fat

42
 Details of Nutritive Value Calculation Of Specific
Food Item
Roti
• Wheat flour (refined) consumed by ~1000gm/meal
the family
• Water added in the flour ~ 3 glass~ 750 ml
• Total dough = 1750 gm
• Multiplication factor = 1000/1750 = 0.57
• No. of chapatis made from this flour = 26
• Weight of one chapati = 1750/26 x 0.57= 38.36gm
• 100gm wheat flour = 348 kcal energy, 11.0gm protein and 2.7mg
iron,1.7g fat
• 2x 38.36 gm of wheat flour = 266.9 kcal energy, 8.4gm protein and 2.1mg
iron, 1.3g fat 43
Details of Nutritive Value Calculation Of Specific
Food Item
Ingredients Amount Kcal Carb Protein Iron Fat
100 gm 30 4 2.6 1.23 0.4
Cauliflower
500 gm 150 20 13 6.15 2
100 gm 97 22.6 1.6 0.48 0.1
Potato
500 gm 485 113 8 2.4 0.5
100 gm 20 3.6 0.9 0.64 0.2
Tomato
250 50 9 2.25 1.6 0.5
100 ml 900 - - - 100
Mustard oil
5 x 15 ml 675 - - - 75
Total ( 8 katories) 1360 142 23.25 10.15 78
1 katori 170 17.8 2.9 1.3 9.8

44
 Details of Nutritive Value Calculation Of Specific
Food Item
Rice
• Rice (raw, milled) 500 gm 3.5 katories
• Water added 7 katories (150 x 7 = 1050 ml)
• Total weight 1500 gm
• Multiplication factor 500/1500= 0.33
• No. of katories made = 7-8
• Weight of one katori = 150 x 0.33= 49.5 gm
• 100gm rice = 345 kcal energy, 6.8gm protein and 0.7mg
iron,0.5g fat
• 49.5 gm of rice = 170.8 kcal energy, 3.4gm protein and 0.3mg
iron, 0.2g fat 45
Details of Nutritive Value Calculation Of Specific
Food Item
Arhar Daal
• Raw daal ~350 gm (2.5 katori)
• Water added ~1200ml (~8 katori)
• 1 tablespoon mustard oil tadka = 2 ×15 ml = 30ml
• Total weight =1550
• Multiplication factor =350/1550=0.22
• Weight of 1 katori = 150 x 0.22 = 33 gm
• 150gm Arhar daal =502.5 Kcal, 33.5g protein, 2.6g fat, 86.4g carb, 4.0mg iron
• 30 ml mustard oil =270 Kcal, 100g fat
• Total = 772.5 Kcal, 102.6g fat
• 33gm katori =141.9 Kcal, 7.37g protein, 18.81g fat, 19 carb, 0.99 mg iron

46
 Details of Nutritive Value Calculation Of
Specific Food Item

Daliya
• Rice (raw, milled) ~75gm (1/2 katori)
• Water added ~225 ml(1-1.5 katori)
• Total weight 300 gm
• Multiplication factor 75/300= 0.25
• No. of katories made ~1
• Weight of one katori = 150 x 0.25= 37.5 gm~38gm
• 100gm daliya = 356 kcal energy, 8.2gm protein and 4.9mg iron, 1.6g fat
• 38 gm of daliya = 135.28 kcal energy, 3.1gm protein and 1.9mg iron, 0.6g fat

47
Calculation Of Salt Intake

Total salt used in family =1.5 kg/month

Total number of family member = 8 (excluding kid)
Per day intake of salt =1500/30=50gm/day
Per day consumption of =50/8
salt/person =6.25g/day/unit

5gm/day recommended, https://www.nin.res.in/RDA_Full_Report_2020.html

48
Physical Examination

49
 Vitals and Anthropometry
Vitals
PR 80 beats per min, regular
BP 140/ 80 mm hg (sitting position)
RR 18 breaths/ min
Temp. Afebrile
Anthropometry
Height 154 cm
Weight 50 kg
BMI 21
Interpretation: with in normal range
Waist circumference 38.5
Hip circumference 36
Waist to Hip ratio 1.06
Interpretation: considered as abdominal obesity (N= 0.85, for females NPCDCS guidelines) 2018)
50
 General Examination
General condition Well oriented to time, place and person
Built Average
Pallor Absent
Icterus Absent Image of Case
Mouth No teeth (fallen after dental caries)
Tongue Pallor absent, clean
Lymphadenopathy Absent
Clubbing Absent
Cyanosis Absent
Edema Absent

51
 Head to toe examination
Head Normal
Eyes Watery, no redness/ itching, diminished vision
Hair Thin and white
Nails Trimmed, clubbing & cyanosis absent
Neck No thyroid enlargement seen, cervical lymph
nodes not palpable
Breast B/L Normal, no skin changes, no palpable lump
Nipples No abnormality seen
Limbs No evident edema, distended veins
Skin Clear and free from disease
52
 Systemic Examination

Respiratory System RR= 18 breaths/ min; Chest: Bilaterally

symmetrical, air entry equal b/l, normal
expansion, no added sounds
Cardiovascular System S1 and S2 normal, no murmurs
Central Nervous Conscious and well oriented with time, place and
System person
Abdomen Soft, Non tender, No organomegaly

53
House and External Environment
Locality Rural
Locale of house Continuous
Type of construction Brickwork
No. of rooms 4
Floor Patient’s Bedroom, front yard and
courtyard- Cemented
Other rooms and backyard
Courtyard Present
Cattle shed Present, Buffalo and Goat

54
 Buffalo
Open area Goat

Straw 4
Cereal store 3
House Plan Bed 2
Kitchen
Drinking water storage
Bathroom and washing area
Open area

Bed
1 Bed

Open area

Toilet
Main entrance
55
 Housing Condition Score Criterion:
Site: bad/fair/good 1 Poor: 10 or less than 10
Fair: 11 to 20
Setback: no/improper/proper 2
Good: above 20
Floor: kacha/pakka with crevices/pakka without crevices 1
Walls: kacha/pakka with crevices/pakka without crevices 1
Roof: kacha/pakka with crevices/pakka without crevices 2
Source: Community
Medicine practical
Height: Inadequate/adequate 1 Guide 2nd edition,
Overcrowding: present/absent 1 Kusumlata Gaur
Light: inadequate/adequate 1
Kitchen: not separate/separate but without smoke outlet/separate with smoke outlet 1
Storage facility: improper/proper 1
Drainage facility: improper/proper 0
Privy: open air defaecation/private service/public sanitary/private sanitary 3
Water supply: surface/well/tap water/tube well or treated tap water 3
Bathroom: not separate/separate but improper/separate and proper 1
Domestic animals: not separate/separateshed 0
Refuse disposal: improper/proper 0
2 56
Drainage: improper/proper 0
Total Environmental score 19 (Fair)
Housing and External Environment

Overcrowding : Present
Natural ventilation : Inadequate- No cross ventilation
Natural lighting : Inadequate
Artificial lighting : Present, Bulb
Dampness :Present
Flies and rodents : Present

57
 Housing and External Environment
Kitchen Details

Place : In the side of the room, not separated

Fuel : LPG gas cylinder, heater & chulha
Smoke outlet : Absent
Utensil washing area : Near bathroom
Drainage of wastewater : Open drain, indiscriminate

58
 Housing and External Environment
Water Supply for drinking and cooking

Source : Submersible
Regularity of water : Regular
Water storage : Covered
Water drawn by : Glass without handle
Kept on ground
Handwash before drawing water : Not practiced

59
 Housing and External Environment

Bathroom and Latrine

Separate : Yes; open

Drainage : Open drain
Privacy : Limited; No door
Toilet type : Pit latrine (two pits) with slab
Construction : Self financed
Handwashing : With soap and water
Solid waste management
Disposal : Indiscriminate
Site :Wasteland in-front the house
60
Image of case house

61
Image of kitchen and courtyard

62
Image of rooms

63
Image of backyard and livestock

64
 Hazards in house
• Discarded tin boxes, bricks, stones and sharp metals over the ground in
backyard
• Presence of rodents and flies
• Boundary not constructed
• House situated on a height and stairs
has no railing
• Inadequate light in inner rooms
where stair is present.
• Kitchen stove and gas placed on the
ground along with knife (Kid)
65
 Psychosocial Aspects
• No pension scheme or Ayushman Card
• Worried about her sons, elder resides outside and younger unmarried
• The family’s income
• Relation between her and her daughter-in-law
▪ Social benefit scheme Card: Patra Grahasthi card
her and younger son
• No Patra Grahasthi card of her daughter-in-law
Image of card of
her and younger son
66
 Differential Diagnosis
Differential
S.N. Symptoms Rule out/ Rule in
Diagnosis
Generalised weakness,
1 Anemia Hb: 12.2 on 10/12/2021
Headache
140/80 mm Hg
Headache, Generalised
2 Hypertension Intake of extra calories, excess salt
weakness
intake, Abdominal obesity
Generalised weakness,
3 Typhoid IgG, IgM positive
Headache
Not associated with vomiting,
2 Migraine Headache
dizziness, aura
No nausea/ bloating/ acidity/
3 Gastritis Headache
indigestion

67
 Final Diagnosis
• Mrs, shanti devi Dubey 75/ F belongs to three generation family and
lower socioeconomic status is a known case of Systemic Hypertension
stage I (diagnosed 2 years ago, without complications ) and is diagnosed
with typhoid 8 days ago.
• Widow and educated till 5th standard
• Diet: deficient in calories, and iron
• BP: 130/90 (19/12/2021)
• Tab Amlodipine and tab Atenolol 25 mg (taking regularly)

68
Change trend of Blood Pressure

Date Readings of BP
11/11/2021 140/90
10/12/2021 150/90
15/12/2021 130/80
19/12/2021 130/90

69
 My comments
• Didn’t rule out other causes of hypertension (like Renal artery stenosis, tumours
of adrenal glands, chronic kidney disease, Arotic Stenosis) : Systemic
Hypertension)
• Especially in old age
• To prevent complications Stroke, Heart d/s ( MI, Heart failure, Artheriosclerosis)
• Advice for the investigations: RBS
LFT
KFT
Creatinine
Lipid profile
ECG
ECHO 70
Web of Causation for Hypertension
Family’s
income
Alone Old age
Daughter- Central
in-law obesity
don’t talk W/H
with her ratio

Younger
Unbalanc
son
ed Diet
unmarried

Older son Reduced

resides Hypertension physical
outside activity

71
Epidemiological determinants for Typhoid

Flies
Uncovered
Open drain
food

Indiscriminate
waste collected
Unfiltered
in front of
water
house (attracts
flies)

No
Low
handwashing
Typhoid immunity
practice before
(Old age)
drinking water
72
 Knowledge Attitude Practice
Knowledge Attitude Practice
Diet Aware that too much salt in diet Positive attitude Consumes whatever
can cause a health problem for salt quantity of salt is in her
restriction in food and don’t add
diet separately
Aware that decreased quantity of Ready to Diet deficient in iron
iron is not good for health improve diet made by daughter-in-law
Aware that increased quantity of fat Ready to Diet rich in fat
is not good for health improve diet

Aware that fruits and leafy Ready to Couldn’t due to no teeth

vegetables is good for health and improve
helps in motion
73
 Knowledge Attitude Practice (Contd.)

Knowledge Attitude Practice

Hygiene Aware of Ready to maintain personal Bathes everyday,
personal hygiene brushes her teeth ,
hygiene wear clean clothes,
takes 6-7 hours of sleep,
washes hand with soap after
toilet use
but drain is open and drinks
unfiltered water

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Knowledge Attitude Practice (Contd.)
Knowledge Attitude Practice
Environmental Aware about Ready to take Wear slippers
hazards actions
Aware about cold Ready to take Not wear woollen
weather actions clothes properly

Physical activity Aware about Ready to take Couldn’t continue

walking in actions walk due to knee
morning and joint pain
evening
Stress Knows that stress Ready to take Couldn’t do anything
and tension actions towards it
affects health
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 Advice at Individual Level
Specific Take BP medications daily
Advice Get BP checked every 6 monthly
Related to Eye check up every 6-7 months
disease Regular follow-up visits
Explained the consequences of persistent high BP
Visit the physician if throbbing headache, blurring of vision,
palpitation, chest pain, breathlessness
Investigations
RBS
LFT
KFT
Lipid profile
Serum electrolytes
ECG
ECHO
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 Advice at Individual Level (Contd.)
Specific To reduce the consumption of salt in diet
Advice Limit the fat consumption
Related to Avoid using deep fried items and limit the use of ghee and oil in meal
disease Eat more seasonal fruits, leafy vegetables and fibres (banana, mousami,
palak, soya methi, sarso saag, carrots) locally available cheap
Not to add extra salt on sabji, salad
Limit pickle, papad
Take small meals frequently (sattu, laiya, seviyaan)
Encouraged to use the glasses regularly
Daily walk in morning and evening
Advised her to take less stress
Advised her for screening of other non communicable diseases (RBS,
cardiovascular diseases, breast cancer)
To keep health records safe
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 Advice at Individual Level (Contd.)

Environmental Wear long sweater to cover her stomach and lower woollen wear
Hygiene Encouraged her to handwash before drinking water and eating food
Awareness regarding COVID, mask/ cloth mask, always handwash
when come home from outside

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 Advice at Individual Level (Contd.)
Physical activity Advised her to visit Ortho OPD for joint pain
Walk and sit in dhoop in frontyard
Stress Play with kid
Make friends in neighbourhood
Sit in sun and chat and laugh with neighbourhood ammajis in
frontyard where neighbourhood boundary meets
Plant 1-2 flowering winter plants in frontyard and take care of them

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 Advice at Family Level

Diet Counselled her daughter-in-law to use less amount of salt in a

(Daughter-in- gradual way
law cooks) (4 teaspoon to 3.5 tbspoon)
Primary
Add palak in dal to make it iron rich Prevention
Reduce the amount of oil (4-5 tbsp to 3-4 tbsp)
Cook palak-sarso saag, grind bathua and mix in wheat flour to
knead (roti), methi aloo sabzi, soya methi sabzi, chana ka saag,
For salad grate carrots/ raddish (backyard)

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 Advice at family level (Contd.)
Diet Encouraged her to grow carrots in her backyard
Try to improve watery dal
May add vegetables like Carrots, Peas
Add lemon juice in dal
Eat jaggery (1 tukda ~ 3-4gm)
Drinking water Tie cloth on handpump’s faucet and boil the water
and Food Handwash before drinking water, after using toilet, before eating,
hygiene handling kid
Keep food and water covered
Use cup with handle to draw water
Children Encouraged for vaccination of kid (16-24 mo)
To educate girls and marriage after 18 yrs
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 Advice at family level (Contd.)

General Keep home clean

Discard / sell discarded waste (tin boxes, broken chair, sharp metal
pieces, broken boxes)
Tie rope for support on stairs and boundary
Social benefit Patra grahasthi
scheme card Apply for Ayushman bharat card
Specific Advice
Mrs. Saroj Encouraged for permanent method of contraception
Mr. Hridesh To check BP at 6-7 month interval (Risk of Hypertension)
Reduce intake of salt
Screen for other NCDs
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 Modified Diet (Day 1) Required: 1419 kcal and 13gm Iron

Time Food item Quantity Calorie (kcal) Protein (gm) Iron (mg) Fat (gm)

7:30 am Tea with cow milk and sugar ½ Glass 58.5 2 0.13 2.6

White bread 2 nos (40 g) 100 3.08 - 0.52

9 am Sattu ½ katori 304 15 7.1 3.75

Roti 2 266.9 8.4 2.1 1.3

12 pm
Aloo-gobhi sabji 1 katori 170 17.8 1.3 9.8
4:30 pm Tea with cow milk and sugar ½ glass 58.5 2 0.13 2.6

Laiya 1 katori 110.4 11.25 9.9 1.5

8:30 pm Daliya 1 135.28 3.1 1.9 0.6

Cow Milk 1 glass 167.5 8 0.5 10.3

Sugar 1 tbspoon 60 - - -

Total 1016.7 44.38 6.06 27.7

402.3 deficient 6.94 deficient
+414.4 + 17
1431 23.06
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