Clinico social case

By VIGNESH MALLYA
3rd Year MBBS
HIMS Hassan
Patient Particulars

 Name – Mrs. Mani

 Age –38 yrs
 Sex – Female
 Education – SSLC
 Religion – Hindu
 Caste- Vokkaliga ; Marital Status - Married
 Adress – H No. 27 Thaneerholla, Hassan
 Slum / Non Slum – Non Slum
 Family Composition
 Nuclear family , Total 4 members in family , HOF Mr. Basavaraj h/o Ms.Mani

Sl.no Name Relatio Age Sex Occupa Educati Income Remark

n to tion on s
HOF

1 Mr.Basa HOF 50yr Male Driver SSLC Earns Rs -

varaj 16,600
/-
2 Mrs.Man Wife 38yr Female Housewi SSLC - Case
i fe

3 Mr.Sand Son 20yr Male Student Diploma - -

esh

4 Mr.sachi Son 15yr Male Student SSLC - -

n
 No H/o any vital events in the past 1year. ( Like Birth ,
death , adoption , Marriage etc., )
Socioeconomic data

 Monthly income – Rs 16,600/-

 Percapita income – Rs.4,150/-
 Class II – According to Modified BG Prasad’s classification ( as on January
2020)
Chief Complaints

Lump in the left breast since 3 months

 Pain in the lump Since 1 month
History of presenting illness

 The patient was apparently alright 3 months back.Then she noticed a

lump in left breast 3 months back , initially it was of the size 1*3 cms
which was noticed accidentally while taking bath, later it progressed
to the present size of 3*3 , 1 month back.
 Associated with Dull aching type of Pain in lump Since 1 month , it
was intermittent, no aggravating or reliving factors.
 Also Itching is present over the Upper outer Quadrant of the breast.
No H/o
 Sudden increase or decrease in the size of lump
 Pain during menses
 Or any discharge or retraction of nipple
 Loss of appetite
 Swelling in the neck or Axilla
 Loss of weight
 PAST HISTORY
 No H/o Of Breathlessness , Hypertension, Diabetes mellitus, Asthma
 No H/o of any previous Surgeries or
 No H/o of Similar complaints in the past
 No H/o OCP use


 FAMILY HISTORY
 No Similar complaints in the family.
Diet History
Item Quantity Energy (kcal) Protein (gm’s)
Tea ( 2tbsp sugar 1 cup 120 1.4
+ 100 mL tonned
milk)
Upma 1 270 8.1
Chutney 4 tbsp 240 2.0
Rice 1 ½ bowl 165 3.0
Sambhar 2 cup 220 10.0
Tea ( 2tbsp + 100 1 cup 120 1.4
mL tonned milk)
Rice 1 ½ bowl 165 3.0
Chiken curry 2 bowl 620 8.4
Total 1,920 40.1
 Recommended calorie = 1,824 kcal /day (5 % reduction due to
obesity)
 Actual calorie intake = 1,920 Kcal /day
. Excess Calorie = 96 Kcal / day

 Recommended Protein = 78 g /day

 Actual protein intake =40.1gm /day
. Protein deficit = 37.9 gm /day
Personal History

Sleep- Sound
 Diet – predominantly vegetarian
 Appetite – Good
 Bowel and Bladder movements- N and Regular
 No H/o Smoking / Tobbaco use
 No H/o of Alcohol consumption
Menstrual History

Age at Menarche – 15yrs , 30 days regular cycle 2 pads /day

 No Dysmenorrhoea

 Marital History-
 Age at marriage -19 yrs
1st Child at 21yrs ; 2nd Child at 26 yrs
 Lactation History-
2 children , both Breastfed till 1 ½ years of age
GPE

 Here is an adult female patient moderately built and

nourished , conscious cooperative, well oriented to Time
Place and Person.
 Ht – 168 cms ,. Wt – 78 kg ,. BMI – 27.6 Kg/m²
 No Pallor , Icterus , Cyanosis , Clubbing,
Lymphadenopathy , Edema
vitals
Pulse rate – 80 beats /min
Respiratory rate – 17 cycles /min
 Temperature – Afebrile
Local Examination

 Inspection- of L breast
 Hands by side of the patient
Size of lump – 10 * 7 cm present in the upper outer Quadrant
Skin over the lump – Normal , no Dimpling , no retraction of nipple ,
no discharges from Nipple, no engorged veins
Areola –Normal
Axilla and Thoracic – Normal
 Both breast move upwards when Hands raised above. Left breast
displaced upwards when compared to Right breast.
 Palpation –
Solitary Lump in left breast , irregular in shape , hard in consistency , All
margins are made out , Smooth surface.
No other swelling in the Breast
No palpable lymph nodes in the Axilla

SYSTEMIC EXAMINATION
RS –NVBS

CVS – S1 ans S2 heard , No murmurs

CNS – Clinically Normal
P/A – Normal , No organomegaly
Family Health & Housing Environment
 There are no health problems in other family member
 Housing
 Lives in Pucca house
 No.of Rooms 2, No.of persons staying 4 , There is overcrowding
 Adequate ventilation, Cross ventilation present.
 Lighting , Natural light adequate
 Rodents are present ,
 Attached kitchen with cooking platform ,LPG used.
 Sanitation
 Domestic waste stored in dust bin and disposed in Public waste bin
 There is a facility of Sanitary latrine for excreta disposal
 Fly nuisance present

Water supply
 Borewell water is the only source of water.
 Water supply is continuous
 Drinking water is stored in clay pots and for other purposes water is stored in
Drum ,which is present outside of the House.

 Child rearing practices

 Children were Breast feed exclusively, but colostrum was discarded
 No artificial milk was introduced
 Immunization was done
Clinico Social Diagnosis
INVESTIGATIONS
 USG
 Mammography
 Blood sugar – 100mg /dL
 Hb % -10.6 gm%
 CBC
 Blood grouping – B +ve
 Serology HIV –ve ; HBsAg – No reaction ; VDRL – no reaction
 FNAC – Ductal hyperplasia

 MEDICAL DIAGNOSIS –
Fibroadenoma of left breast with Ductal hyperplasia
EPIDEMIOLOGICAL DIAGNOSIS
 Fibroadenoma of left breast may be due to some of the Risk factors like age ,
above 35 yrs , obesity and High fat die
Knowledge ,Attitude ,and Practice (KAP)

 When we asked ,she said that she wasn’t aware of the disease.
 She had ignored it when the lump was small in size ,which later progressed
into a big one.
 Other family members ignored the matter initially when she tried saying the
same.
 So the attitude of the patient and the family member towards the disease –
Not Rationalistic
 There is a KAP gap
 Advice ,
To the family members to take the atmost care of the patient.
Explaining the consequences in detail as most of the breast lumps might
not be cancerous. Recommend Treatment guidelines based on the family’s
socioeconomic Backgrounds.
Clinico social Aspects

 NEGATIVE ASPECTS
 Risk of spread of cancer to the normal breast
 Female gender
 Obesity and sendentary life style practices
 Non veg diet which she consumes
 POSITIVE ASPECTS
 Along with house work going for a walk in the morning and evening
 Self Breast examination once in a week
 Stick to Vegetarian diet , should stop eating meat
 Visit the nearest Doctor once a year , Mammography to be done.
Management

Medical Management /Non Surgical Management

Systemic Harmone therapy – TAMOXIFENE
Vitamin E supplements
Cryoablation

Surgical Management
 Simple Mastectomy or Lumpectomy can be performed
 Radiptherapy after surgery
 Preventive Treatment
 As the Risk factors were , obesity and High fat diet that she was consuming , Advice to be given
not to consume such foods , Changes in the life style with regular exercise and healthy balanced
diet.
 Promotive Treatment
 Community level – Organizing Health education camps for Breast self Examination (BSE)
THANK YOU