DEPARTMENT OF
COMMUNITY MEDICINE
CLINICO-SOCIAL CASE DISCUSSION
PRESENTED BY:
ARTI GUPTA 103
MEHWISH WASEEM 102
SATYANARAYAN 88
SATYENDRA KUMAR 89
SACHIN KUMAR ARYA 85
GENERAL INFORMATION
➢ Head of the Family : Puran Chandra
➢ Age : 47
➢ Residence : Village- Ashoka, Deeha, Bahraich
➢ Religion : Hindu
➢ Type of Family : Nuclear Family
➢ Date of Interview : 02.09.2022
FAMILY COMPOSITION
➢ The family comprises of 5 members including the head of the
family. There are 3 adult males, 2 adult females.
S. Name of the Age Gender Relation to Education Marita Occupatio Income Any Disabilit
no. family member the head of status l n Per month illness status
the family Status
1 Puran 47 M Head 12th Pass M PWD 32000 Hyperte -
Chandra Service nsion
2 Shanti Devi 42 F Wife Illiterate M Housewife - - -
3 Dileep Kumar 24 M Son Graduate - Tailor 7500 - -
4 Pradeep 22 M Son 12th Pass - - - - -
Kumar
5 Bindu Kumari 20 F Daughter 11th Pass - - - - -
SOCIO-ECONOMIC STATUS
➢ The socio-economic status of the family according to Modified
Kuppuswamy’s classification is Lower Middle Class (Class III).
Education of head of family 12th Pass 5
Total monthly income 39500 4
Occupation of head of family Skilled Worker 6
Total score 15
ENVIRONMENTAL DETAILS
➢ The family live in their own house, there were 2 rooms in the house. The
House was pucca and floor was cemented.
➢ Kitchen was separate and LPG used as source of fuel. Food articles were
covered.
➢ Lighting and ventilation was adequate, Overcrowding was present, Breeding
places for insect were present.
➢ The source of drinking water was hand pump, it is collected and stored in
bucket.
➢ Solid and liquid waste disposal was indiscriminate type and sanitary latrine
was present.
RECOMMENDATIONS
➢ Chances of contamination was present so we advised them to use bucket with lid.
➢ Mosquito net can be used.
➢ Dustbin should be used to collect the household waste.
➢ Do not allow water to collect around the house to eliminate mosquito breeding.
HOUSING MAP
Entr
y
CASE HISTORY
Name – Puran Chandra Age- 47 Sex- Male
Address- Village- Ashoka, Deeha, Bahraich Occupation :- PWD Service
CHIEF COMPLAINTS
Headache (since 6 months)
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6 months back followed by recurrent episodes of headache and
dizziness. For which he took common medicines like paracetamol for about 3 months but when the
symptoms got more severe and frequent patient visited to a District Hospital. Where he was diagnosed
with hypertension with BP 152/98mmHg. At that time his complaints were:-
● Fatigue started 6 months back
• Associated with weakness in body
• Aggravated on stress and on long hour work.
● Headache started 6 months back.
• Headache was sudden in onset and tension type.
• More in morning and localised in frontal region.
• It was pulsatile in character and was non radiating.
• Associated with nausea and dizziness.
• Aggravated by stress and long duration work which get relieved on medication.
● Vomiting occurred 3 months ago after fatigue and headache.
• There were 1-2 episodes of vomiting per day which occurred for about 5 days.
• Associated with nausea and dizziness
• It was clear with food particles
• No blood was present in vomiting
• It was non-projectile type.
Now the patient is on regular medication from past 3 months as prescribed by the doctor.
PAST HISTORY
● No similar episodes in past.
● Not a known case of DM/ASTHMA/COPD/TB/Cardiac illness
PERSONAL HISTORY
● He has normal appetite with regular bowel and bladder movement and take 7-8 hours of sleep.
● He dose not smoke or consume alcohol and not indulge with any other addiction.
DRUG HISTORY
● Patient is taking treatment for the Hypertension for which he is taking:-
Telmesartan 40mg OD
Amlodipine 5mg OD
FAMILY HISTORY
● No relevant family history.
DIETARY HISTORY
● Type of Diet Consumed - Vegetarian
● Average Requirement was - 2110 kcal/day.
● Total intake was of 2390.8 kcal with an excess of 280.8 kcal.
● Total protein intake was 48.43gm and requirement is 56.44g.
● Total salt intake was 8-10 gram/day.
DIETARY CHART (24 HOUR DIETARY RECALL
Sessions Items METHOD) Calories Proteins
Breakfast Chai 1 Cup 100 kcal 1.05 gm
Roti 2 160 kcal 4.8 gm
Biscuit 4 90.8 Kcal 1.38 gm
Banana 1 90 Kcal 1 gm
Lunch
Roti 4 320 kcal 9.6 gm
Rice 2 Katori 340 kcal 4 gm
Veg 1 Katori 170 kcal 1 gm
etabl
e
Evening Snack Banana 1 90Kcal 1 gm
Dinner Roti 4 320 kcal 9.6 gm
Rice 2 Katori 340 kcal 4 gm
Sabzi 1 Katori 170 kcal 1 gm
Dal 1 Katori 200 kcal 10 gm
DIETARY ADVICE
●To reduce salt intake (not take more than 5 gm/day)
For which he should separate the cooked food before the addition of salt in it(or may use less
amount of salt) after that the family can add salt according to their need.
●He should not take saturated fat
like butter, ghee, cake, cheese etc.
●Follow DASH diet (rich in fruits , vegetables ,low fat dairy products)
● To increase dietary fibres
For which can eat sprouts, fruits, vegetables etc.
EXAMINATION
GENERAL EXAMINATION
● Patient was examined in comfortable sitting position and was well oriented with
time, place and person.
● Height:-165 cm, Weight :- 68kg, BMI- 25. He was Obese in body build.
● Blood Pressure- 136/88 mmHg
● Pulse- 86 beats per min
● Thyroid gland- Not enlarged
● Neck Veins- No engorgement
● Temperature- Afebrile
● No Pallor
● No Icterus
● No Cyanosis
● No Lymphadenopathy
● No Clubbing
SYSTEMIC EXAMINATION
➢ Cardiovascular System
● Inspection
Shape – Normal and absence of any deformity
Engorged Veins – Absent
Scar Mark- Absent
No pulsation present out side precordium like Aortic area , suprasternal area ,
supraclavicular area
● Palpation
Mitral Area – Apex Beat Normal in position
Thrill- absent
➢ Respiratory System
● Inspection
Respiratory rate - 18/min ,
abdominothoracic breathing Bilaterally
symmetrical with no scar found
● Palpation
Surface temperature normal.
Normal position of trachea & chest
expansion.
● Auscultation
Normal vesicular breathing sound
➢ Abdominal examination
● Inspection
Rounded abdomen with no venous prominence &
umbilicus central and inverted.
● Palpation
Normal surface temperature with no tenderness.
● Percussion
Dull notes of abdomen found with full urinary bladder.
● Auscultation
Normal bowel sound.
MANAGEMENT OF HYPERTENSION CAN BE
DONE AT DIFFERENT LEVELS:
➢ AT INDIVIDUAL LEVEL:
●Maintain normal body weight.
● Consume a diet rich in fruits, vegetables, and low fat dairy products with a
reduced content of saturated fat and total fat.
●Reduced dietary sodium intake.
● Should do daily physical activities such as brisk walking (at least 30 minutes a
day yoga, cycling, etc.
●Take medication on time.
●Should measure Blood pressure regularly.
➢ FAMILY LEVEL-
● Family members should motivate him to take proper diet (DASH Diet) and
timely medication and promote for exercise.
● Family members should be screened for hypertension time to time.
• AT COMMUNITY LEVEL:
● Give awareness about disease, health education to the high risk group of the
community, lifestyle modification including primordial prevention among adolescents,
importance of adherence to medication, diet and exercise .
● Give information regarding the symptoms and complications of Hypertension.
RUNNING PROGRAMMES
➢ NPCDCS
● NPCDCS (National Programme for Prevention And Control Of Cancer,
Diabetes, Cardiovascular Diseases And Stroke)
● Programme launched in 2010 (revised in 2013-17) working at the community
level.
● Strategy of this programme is health promotion, awareness in generation and
promotion of healthy lifestyle, screening and early detection, timely affordable and
accurate diagnosis, access to affordable treatment, rehabilitation
THANK YOU
