Asmita cmfm.pptx family case assigned .....

Clinco psycho social case

1. CLINICO-PSYCHOSOCIAL CASE REVIEW NAME OF THE PRESENTER: Asmita Reddy BATCH: 2022 ROLL NO: 28 DATE OF FAMILY ALLOTMENT: 20/07/2024 NO. OF DAYS OF VISIT ALLOTTED: 4 NO OF DAYS VISITED: 4 ALL INDIA INSTITUTE OF MEDICAL SCIENCES, GORAKHPUR .

2. CONTENTS OF CLINICO- PSYCHOSOCIAL CASE REVIEW The objective of Clinico- PsychoSocial Case (CSC) taking is to examine the “Index Case” in the context of Clinical History & Examination Family/Demographic Details Environmental findings Social history Comprehensive Diagnosis Comprehensive Treatment

3. Identification and Family Information Head of household: Santosh Pandey Age: 35 Sex: Male Marital Status: Married Religion: Hindu Occupation: private pharmacy Address: New colony, Singharia,Gorakhpur

4. Family / Demographic Details A. Type of family: Joint family B. Total number of family members:9 C. Socio-Economic Status of the family Total monthly income of the family: Rs. 60,000 Per capita income per month of the family : Rs.6666 Education(HOH) – 6 Occupation(HOH) – 6 Income(Family) – 6 Total score – 18 (between 16-25) Socioeconomic class – Upper Middle (II) By Modified Kuppuswamy Scale D. Type of Ration card : Nil

5. Name Age(yrs) Sex Relation with HOH Education Marital Status Occupation Income( per month in Rs.) 1.Santosh Pandey 35 Male Self B.pharma graduate Married Private pharmacy 30,000 2. Thakur Pandey 40 Male Father deceased Graduate Married nil nil 3. Brijranti Devi 50 Female Mother Till Middle school Widow nil nil 4. Arun Pandey 38 Male Older brother Post-graduate mba Married Pharmacy private 30 000 5.Kajol Pandey 30 Female Wife Graduate Married nil nil 6.Anjali Pandey 30 Female Sister in law Graduate Married nil nil 7. Yashvi Pandey 6 Female Daughter Class 1 Unmarried nil nil 8.Om Pandey 3 Male son Play school Unmarried nil nil 9.Aditya Pandey 10 Male Nephew Class 4 Unmarried nil nil 10.Golu Pandey 6 Male Nephew Class 1 Unmarried nil nil

6. Pedigree Chart .

7. INDEX CASE Name: Om Pandey Age: 3 year 9 months Date of Birth: 23 Oct 2020 Sex: Male Religion: Hindu Address:New colony Singharia, Gorakhpur

8. Informant Name: Kajal Pandey Relationship to the child: Mother Age of the informant: 30 years Gender: Female Occupation: Unemployed Primary caregiver to the child. Reliability of the informant: The mother appeared to be consistent and reliable in providing information

9. Medical History of Index Case Chief Complaints : Poor weight gain since 9 months with no other chief complaints.

10. History of Present Illness Patient was apparently asymptomatic 9 months ago after which he started having poor weight gain when complementary feeding was stopped as informed by the mother. The child has a normal appetite. There are no associated symptoms. The patient has no history of chronic illnesses or frequent infections. Mother also reported child’s aversion to fruits and vegetables and a diet predominantly composed of carbohydrates. .

11. No H/O convulsions No H/O rashes No H/O fever No H/O cough No H/O ear drainage No H/O vomiting No H/O diarrhoea No H/O jaundice

12. Past History No H/O recurrent infections No H/O significant illnesses No H/O hospitalization

13. Birth History Antenatal History (H/O Pregnancy): Health and Nutritional Status of Mother during pregnancy: Healthy Illness during Pregnancy: None reported Infections during pregnancy: None reported Drugs: Iron and folic acid supplements were taken X-Rays: No exposure to radiation in first trimester TT (maternal vaccination against pregnancy): Vaccination taken Past Obstetric: G2P2L2A0

14. Birth History (Contd..) Natal History (H/O Delivery) Place of Delivery: Pragati Maternity Home, KunraghatGorakhpur Conducted by: Physician Gestation time: 38 weeks Labour time: 2.5 hours Presentation and type of delivery: Cephalic presentation and vaginal delivery Complications: Not reported.

15. Birth History (Contd..) Post Natal History: First Cry: Immediately No resuscitation required, no problems in swallowing, no respiratory problems Birth Weight: 2.7 kg Birth Injury: No birth injury Convulsions, Cyanosis, Jaundice, Fever, Rash: No signs reported

16. Breast Feeding History: Onset of feeding: Within 1 hour Type of feed: Breast milk Exclusive breast feeding: For 6 months Pre lacteal feeds: No pre lacteal feeds were given to the child. Associated problems in feeding: None reported Weaning: When: After 6 months What: Boiled and mashed potatoes , Daliya Amount: small bowl Frequency: Twice a day Complementary feeding: Up to 2 years post partum

17. Family History No significant family history Father: 35 years old, healthy, no chronic illnesses reported. Mother: 30 years old, healthy, no chronic illnesses reported. No H/O of genetic disorders in the family.

18. Developmental History There is no history of developmental delays. No red flag signs detected Milestones: Social/Emotional : Plays with other children Communication : Follows directions and has no difficulty in understanding Fine and Motor Cognition: Is able to draw lines and circles Gross motor: Can play catch and throw a ball. Can climb stairs . Can jump with two feet together.

19. Immunization History of the Index Case Vaccine Given or not BCG, Hep B-birth dose, OPV-zero dose Given (BCG scar present) OPV-1, Rota-1, fIPV-1, PCV-1, Pentavalent-1 Given OPV-2, Rota-2, Pentavalent-2 Given OPV-3, Rota-3, fIPV-2, PCV-2, Pentavalent-3 Given MR-1, Vit A, JE-1, fIPV3 PCV-booster Given DPT first booster dose, OPV first booster dose, MR-2, JE-2 Given DPT second booster dose Yet to be administered

20. 24 Hour Dietary Recall Date Tim/e of the meal Rice Chapatti Dal Vegetables Tubers Sugars Tea/Coffee Milk and milk products Fish / Meat Eggs Fruits Others (21/07/2024) Breakfast 1(40gm)) 100g Lunch 1 (40gm) 25gm Evening 20gm Dinner 1(40gm) 100gm Total 80gm 200gm 25gm 20gm 100gm (22/07/2024) Breakfast 1(40gm) 100g 5gm Lunch 40gm 25gm Evening 20gm Dinner 1(40gm) 100gm Total 80gm 200gm 25gm 25gm 100gm (23/07/2024) Breakfast 2( 80) 100g 5gm Lunch 1 (40gm) 25gm Evening 20gm Dinner 1(40gm) 100g 100gm Total 120gm 200gm 25gm 25gm 100gm .

21. Total calorie recommended= 1200-1400 calories. Calories Consumed: 828 Calorie deficit = (472) =63% Protein recommended = 16-20gm Protein intake=18 gm No protein deficit

22. Physical Examination The patient was examined in a well lit room and was conscious cooperative and well oriented to time, place and person. General Appearance : The child appears to be of thin built with no signs of wasting. There is no evidence of pallor, icterus, clubbing, cyanosis, lymphadenopathy and oedema. Anthropometry Weight: 16.0 kg Weight for age z score: Between median and 2 SD normal Height: 102.0 cm Height for age z-score: Between median and -2 SD normal Mid Upper Arm Circumference: 15.6 cm normal Weight for height z-score: Between median and 1 SD normal Head Circumference: 51 cm normal BMI: 15.4kg/m2 normal

23. Vitals: RR: 26 breaths/min Pulse: 84 bpm Temperature: 98.8 degreeF Head to Toe Examination: Head: Normocephalic, head circumference = 51 cm (normal for age according to z-score in WHO growth standards, no rashes on scalp, no loss of hair, no brittle hair. Eyes: No signs of infection, no bitot’s spot seen; pink conjunctiva Nails : no signs of brittle nails no paleness or clubbing Nose: No discharge Ear: No pus discharge, no loss of hearing ability Mouth and Throat: No gum bleeding, no evidence of dental caries, no inflamed tongue, no cheilosis, lips and palate normal in development Chest: Round in shape, moves symmetrically with breathing. Abdomen: Flat, no scars, no discharge from umbilicus, no scars seen. Skin: no signs of dry skin.no cutaneous lesions ,petechies itching or redness

24. Clinical Provisional Diagnosis The patient is a 3 year old child with normal growth (z-score: between median and -2) and has normal weight according to age (z-score: between median and -2) according to WHO growth standards.

25. Environmental Findings House Type of house - Pucca Overcrowding - Absent Ventilation—Inadequate Lighting Natural light—Inadequate Artificial light—Adequate Household hazards – Absent Mosquito breeding areas —Absent Rodents in the house—Absent Pets in the house—Absent Cracks and crevices—Absent

26. Environmental Findings(Contd..) Kitchen > Separate and open > Floor type- non slippery , cemented > Clean > Storage of cooked food – closed utensils > Storage of uncooked food- refrigerator and packed container > Fuel used- LPG > Smoke outlet—present > Drainage—closed Water supply > Continuous > Source of drinking water : R.O. > Storage of drinking water: Closed container > Evidence of mosquito breeding in the stored water (inside the house) - absent

27. Environmental Findings (Contd..) Refuse disposal How stored inside house : Covered dustbin How disposed out of the house: Waste Collector (Nagar Nigam ) Frequency of disposal: once a day Latrine Shared Type of latrine- Indian

28. Psycho-Social History Maternal and Child Health Practices: Pregnancy: No significant customs during pregnancy, antenatal care taken routinely. Physical activity during pregnancy: Present Child rearing practices: Special practices such as oil bath and kajal application: No Usual time of commencement of breast feeding: Within 1 hour Colostrum: Given Prelacteal feeds: Not given Artificial milk during pregnancy: Not given. Age of Commencement of weaning: After 6 months Attitude regarding childhood immunisations: given on time

29. Psycho-Social Diagnosis Upper Middle Socio Economic Status No Overcrowding Inadequate ventilation Inadequate natural lighting

30. Interventions For the index case: Giving the child a balanced diet, following hygiene practices during preparation of food and going for regular health check ups. Diet plan: Consisting of high calorie diet along with the addition of fruits, leafy vegetables. Regular monitoring of weight, height and MUAC. Frequent smaller meals

31. At family level: Parental Counselling: Importance of nutrition, food preparation and feeding practices

32. Environmental Interventions Segregation of dry and wet waste. Proper hygiene practices. Regular cleaning of water tanks.

33. THANK YOU!!!