CLinico-social case presentation

Demographics

 Name: XXX
 Age: 52 years old
 Sex: Female
 Language: Tamil
 Religion: Hindu
 Education: Not studied
 Occupation: Housewife
 Address: 114, Kamaraj nagar, Thuthipattu, Vellore
 Informant: Patient’s husband
 Reliability: Good
 Presenting complaint

K/c/o: CVA(19/1/21)
B/L pontine & basilar ganglia infarction .
Systemic hypertension
Vasculitic workup under evaluation

Admitted for initiation & titration of anticoagulants in view of thrombotic disorder under
evaluation.
 History of presenting illness
DATE SYMPTOMS HOSPITAL DIAGNOSTIC MANAGEMENT

5/1/21 Dizziness x on Private hospital in nil Medications

evening kallakurichi given(details not
Urinary incontinence x available)
at sleep

5 days later Unconscious sudden Ayurveda hospital nil Alternative

in onset(evening). medications
Regained
consciousness
spontaneously within
minutes
DATE SYMPTOMS HOSPITAL DIAGNSTICS MANAGEMENT

19/1/2022 At evening , Adukambarai GH Ct Imaging revealed Discharged at

weakness of right B/L pontine & request
extremities, 3 days midbrain infarction
later not able to
speak.
Narayani hospital MRI:T2 Due to financial
hyperintensity in issues discharged .
pons.
MRA:acute infarcts
in bilateral pons &
cerebellum,with
basilar artery & V4
segment of left
vertebral artery.
DATE SYMPTOMS HOSPITAL DIAGNOSTICS MANAGEMEN
T
CMC CT NG Feeds &
BRAIN:acute indwelling
infarct in b/l catheters.
hemipons &
chronic lacunar Started on
infarct in b/l therapeutic
basal ganglia anticoagulation
for a period of 5
Carotid days.
Doppler:Non
visualization of
b/l vertebral
arteries
HOSPITAL DIAGNOSTICS MANAGEMENT

CMC Apla, vasculitic, Catheter removed after trial

Hyperhomocystenemia of void.
workup was negative.
Discharged on
Echo & ECG –LVH with request(financial issue)
grade 1 diastolic
dysfunction,

Lipids profile were normal.

HOSPITAL DIAGNOSTICS MANAGEMENT
CMC CHAD OPD For regular antihypertensive
medications.
Rehabilitation Institute For upper limb
strengthening exercises &
lower limb passives.
Currently under PMR for
further neurorehabilitation
CONDITION AT ADMISSION

 Afebrile
 Able to sit in wheelchair
 Partially dependent on bed mobility, functional abilities
 Partially dependent in feeding & upper half dressing
 Dependent in all ADL’s
 Obey simple commands.
 Bladder:Indicating, self void
 Bowel:Indicating, self pass
Past history

 Hypertensive for 2 years & not on regular Medication

 No history of diabetic mellitus.
 No past surgeries.
 FAMILY history

 No history of similar illness in the family

 No history of DM,HTN or malignancy in father or mother

30 25 20
 Relation to the
SN Name Age Education Occupation Income Health issue
patient

Cleaner in Not currently

1 x Husband -
lodge working.

Disablity
2 y Wife(patient) - Housewife HTN,CVA
Pension

Assistant
3 z Son 12th
1000/month -
electrician
Personal history

 Occupation: House wife.

 Not able to do House works since illness.
Socioeconomic history

 Monthly income of family: before 2 years, Rs.7000

 Per capita income: Rs.1000- 2000 (son)
 BG PRASAD SES SCALE: Class IV, lower middle class
 Monthly expenditure pattern
 On food and groceries: 600/month(Rice,Dal,Sugar,Oil from Ration shop)
 On electricity, telephone bill and water charge: Rs. 300
 On gas:Monthly 1170
 On medical needs: getting free medicines after admitted in CMC.
 Loans: Rs 40,000 (Have not repaid)
External environment

 Any accident prone area: No

 Street lights: Present
 Stray animals: Present
 Open drains: Present
 Vector breeding sites: Present
Internal environment
 Type of the house:
 In relatives
 Kuccha/pucca: Mixed
 Floor: Even
 Roof: Asbestos
 Cracks and crevices: present
 Dampness: present

 Number of living rooms: 1 hall 1 room

 Ventilation:
 No. of windows present: 2
 No. of doors present: 1
 Cross ventilation: Absent
 Indoor air pollution: No
 Lighting:
 Adequate
 Able to read newsprint in any 2/3rd portion of the house: Yes
 Kitchen
 Platform: Present
 Floor type: Cemented floor
 Whether platform is used for cooking: Yes
 Clean
 Fuel used: LPG
 Storage of cooked food: Closed Container
 Storage of uncooked food: Unclosed Container
 Smoke outlet: Present
 Smokeless Chulha: Absent
 Washing area for utensils: Yes
 Disposal of sullage – open drain
 Bathing place:
 Privacy: Present
 Light: Adequate
 Maintenance: Poor
 Drainage: Open
 Toilet:
 Indian style
 Solid waste management:
 In the house:
 Container used: Yes
 Segregation of wastes in to bio-degradable and non-biodegradable: No
 Frequency of disposal: Daily
 In the area: Present
 Distance from the house: 10 m
 Door to door collection: yes
 Container: Present
 Frequency of evacuation: Daily
 Accesibility to animals: Pets in the house: Absent
 Vector menace in the family: Mosquitoes
Healthcare facility

 Nearest: Adukkamparai Government hospital

 CHAD: 3.5 km
General examination

 Moderately built, well nourished

 VITAL SIGNS:
 Pulse rate: 92/ min
 BP: 100/70 mm hg
 Temperature: Afebrile
 RR:22 /min
 No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
 Systemic examination

 CNS Examination:
 Conscious, oriented to place
 Speech: Spontaneous speech is absent, follows all commands
 Fluency: Absent, dysarthria+
 Reading:Absent
 Writing:present
Cranial nerves:
7th nerve:deviation of angle of mouth to left.Forehead wrinkling normal &
able to close both eyes.
 Motor System:
 Upper limb:Left side is 4 & right side is 2
 Investigations
 PT with INR:13 (11.7-16.1) INR:0.98 at 24/01/2023
 CBC: Hb:11.6,TC:8200(n:53, ly:36), Plt:3,13,000 at 19/01/2023.
 LFT:ALP(145) at 19/01/2023.
 Up/Uc:0.23 mg/dl 19/01/2023.
 C3-128,C4:32.1(wnl) at 19/01/2023
 ANA:1+ at 16/01/2023
 DS DNA:198 at 16/01/2023 (inc)
 Anticardiolipin:46 at 16/01/2023(inc)
 IgM Ab to B2 GP1 complex-<2 at 19/01/2023
 IgG Ab to B2 GP1 complex-36 at 19/01/2023(inc)
Diagnosis

 PROBABLE APLA
 CEREBRO VASCULAR ACCIDENT(19/1/21)
 B/L PONTINE & BASILAR GANGLIA INFARCT
 RIGHT HEMIPLEGIA WITH SENSORY APHASIA
 SYSTEMIC HYPERTENSION
Treatment given

 As her INR was 0.98 she was started on warfarin 2mg OD &
Inj.Enoxaparin 60mg BD.
 Repeat INR on 27/01/23 1.04, warfarin increased to 5 mg od &
Inj.Enoxaparin 60mg BD.
 Repeat INR on 30/01/23 1.40, warfarin increased to 6 mg od &
Inj.Enoxaparin 60mg BD.
 KAP regarding health and disease
 Knowledge:
 Aware of the disease and thinks that it was caused accidently.
 Attitude:
 Are they willing to follow the same system of medicine for treatment-Yes
 Are they willing to consult the doctor at regular intervals- Yes
 Are they willing to follow the same advice given by the doctor-Yes
 Practice:
 Which system are they following now for treatment- Allopathy
 Are they consulting their doctor at regular intervals- Yes
 Is he taking his medications regularly: No
ICE

 Based on her huband’s view

 Ideas: Understanding and willing to accept treatment
 Concerns: Concerned about her cost of treatment,about the time taken to
return back to normal.
 Expectation: Complete ambulation from her illness and return back to
work
 Problem list
Factors Problem Intervention
MEDICAL RIGHT HEMIPLEGIA WITH TO CONTINUE ON REGULAR
SENSORY APHASIA ANTICOAGULATION & VISIT
REHABILITATION INTERVIEW

FINANCIAL LOW SOCIOENONOMIC STATUS MEDICAL SUPPORT

GIVEN BY CHAD

ENVIRONMENTAL … ….

….. ….
Clinico social diagnosis

 Misses. Malliga, a 52 years old female, housewife.

 She belongs to class IV socio-economic class according to B.G.Prasad
classification
 She lives in a cement house with inadequate ventilation, mosquito
breeding sites and poor drainage system
 She is diagnosed to have APLA Syndrome lead to Right hemiplegia with
sensory aphasia.
Thank you!