CLINICO-SOCIAL CASE PRESENTATION

University of Medicine (1), Yangon

PSM Posting Group 5, Sub-group A

Roll No. 1 – 30

FOR THIS CLINICO-SOCIAL CASE,

Case taking: Done by the whole sub-group

Presenter: Kyaw San Lin (RN - 21)

Computer: Kay Yu San (RN- 4)

KK Thwe Sunn (RN - 1)Kyaw San Lin (RN - 21)

Pamphlet: KK Thwe Sunn (RN - 1)

CONTENTS

Personal CharacteristicsSummary of Relevant Social & Community Aspect

Summary of Clinical AspectsAnalysis of the ProblemManagementSummary of the Case

PERSONAL CHARACTERISTICS Age 29 Sex Female Race and Religion Myanmar, Buddhist Education 4th Standard Marital status Married Number of children 2 Occupation Selling rice & pickled tea (La-phat) at Thein Phyu Night Bazaar

PERSONAL CHARACTERISTICS Date of Admission 24th August, 2014 Hospital Ward Unit 3, B Block, Central Woman Hospital

Father Name U Sein Win Occupation Manual Worker Education Read & Write

Mother Name Daw Shwe Mi Occupation Manual Worker Education Read & Write

SUMMARY OF RELEVANT SOCIAL & COMMUNITY ASPECTPersonal HistoryOccupational HistoryFamily HistoryAttitude towards her illnessSocial Environmental History

PERSONAL HISTORY

Well conscious and can respond to questions

Hobby - Watching TV, mainly moviesDoesn’t have any ambition

HER LIFE EVENTS

Childhood life at Zwe

Htaw village

Moved to Yangon

Life after Marriage

CHILDHOOD LIFE AT ZWE HTAW VILLAGE

• Parents - poverty

• Many siblings

Born from a poor family

• Only Elementary school present

• Both parents can only read and write

Primary education at the village • Far from town

• An hour drive by motorcycle to nearest town Thone khwa

For higher levels of

education…

LIFE EVENT AFTER MOVING TO YANGON CITY

Moving to Yangon to her elder brother at the age of

19

Assist household works for

her brother’s

family

No further Education and health knowledge

gained

Met her husband-to-

be while hiring

Trishaw

MARRIAGE LIFE

Age of marriage – 21 yrs

After 3 yr (age of 24) – 1st child

After another 2 yr (age of 26) – 2nd child

Now, after another 3 yr (age of 29) - 3rd child pregnant and income becomes insufficient

Lead her to sell goods at the night bazzare

OCCUPATIONAL HISTORY

Working hours

From 10 pm to 4 am

Abnormal sleeping pattern

Hours of sleep per day

4 hours

Insufficient hours of sleep

• Selling rice & pickled tea (La-phat) at Thein Phyu Night Bazaar

FAMILY HISTORY

•4 members•Nuclear type

Her husbandPatient

2nd child1st child

HER HUSBAND

Age – 33 yearsEducation – 4th StandardOccupation – trishaw driverDaily income – 5000 kyats

HER CHILDREN

First child - 5 years old, lives with her grandparents at Zwe Htaw village since 2012.

Second child – 3 ½ years old, sent to her grandparents since she have the present pregnancy

ATTITUDE TOWARDS HER ILLNESS According to her… She has never worked as sex worker No pre-marital sexual activity No extra-marital sexual activity Never transfused blood before

So,… Realised that she got this disease from her beloved husband.

Already known the chances of exposure to premarital and extramarital sexual exposure during his working period and environment.

ATTITUDE TOWARDS HER ILLNESSBut,… She understands her husband’s situation Still loves him… Wants to take medication regularly together with her husband.

To get be able to live with her family happily as normal people.

HER CURRENT ENVIRONMENT Lives only with her husband in a 10 square feet room Shared with other families. Share bathrooms and toilets.

Transportation - easy from her house. Bazaar - near her house and she can go easily. Water supply - from the Gyo Phyu water pipeline. Latrine - sanitary with septic tank attached. Refuse disposal - in a nearby public bin. Clinics and hospitals - situated near her house

SUMMARY OF CLINICAL ASPECT

HistoryPhysical Examination InvestigationsProvisional Diagnosis

HISTORY

Admitted to the Central Women Hospital (CWH)

On 24th August, 2014 For acute gastritis and PMCT programme

MENSTRUAL HISTORY

Age of menarche - 13 years. 28-week cycle, lasts for 3 days, regular, moderate amount, no dysmenorrhoea.

LMP - 3rd January, 2014 (not sure)MBD - 33 wks 6 days EDD - 10th October, 2014

PAST OBSTETRIC HISTORY

The age of marriage - 21 years. Single marriage. G 3, P 2+0.Her 1st child - 5 years old, born at term by urgent LSCS d/t APH d/t placenta praevia. No 3rd stage & puerperal complications.

Her 2nd child - 3 ½ years old, born at term by elective LSCS d/t previous LSCS. No 3rd stage & puerperal complications.

HISTORY OF PRESENT PREGNANCYUnplanned but wanted pregnancy. Dx of pregnancy by UCG on March. Signs and symptoms of pregnancy such as morning sickness, and amenorrhoea are also present.

Took AN care at 6th month of pregnancy at CWH.

HISTORY OF PRESENT ILLNESSacute onset dull aching pain in epigastrium 1 day duration aggravated by taking food relieved by taking antacidnot severeNo radiation

PAST MEDICAL & SURGICAL HISTORY

No past history of H/T, DM, IHD, epilepsy, TB, renal diseases or other diseases.

No history of hospitalization. No past surgical history.

PAST GYNAECOLOGICAL HISTORYNo past gynaecological diseases, operations or treatment.

Screening of cervical smear has not been done before.

FAMILY, DRUG & PERSONAL HISTORY

No family history of H/T, DM, PE, or twin pregnancy.

No other genetic diseases present.No regular taking of drug. No known drug allergy.No smoking, alcohol drinking, betel chewing or drugs addiction.

CLINICAL EXAMINATION

GeneralCNSCVSRespiration LymphaticsBreastAbdomen

GENERAL EXAMINATION Well alert, well orientated, lying comfortably in the bed, no fever, slightly thin.

Eyes: Pallor present. No Jaundice. Mouth: Teeth and gum are healthy. No tonsillar enlargement.

Neck: No visible swelling in the neck. Extremities

Upper limbs: NAD Lower limbs: No clubbing, no peripheral cyanosis, bilateral pitting petal oedema present.

CNS EXAMINATION

Well alert, well orientated. Normal cranial nerves, sensory, motor and peripheral nerves functioning.

CVS EXAMINATION

BP- 110/70 mmHgPR – 70 beats/min Apex beat - located at the left 5th ICS within the mid-clavicular line

Normal 1st and 2nd heart sound No added sound

RESPIRATORY SYSTEM EXAMINATIONNormal vesicular breath soundNo added soundRR – 16/min

LYMPHORETICULAR SYSTEM

No lymph node enlargement.No liver enlargement. No splenic enlargement.

BREAST EXAMINATION

Well developed. Nipple is protruded. On palpation of the four quadrants, no abnormal lump is palpated.

ABDOMINAL EXAMINATION (SUMMARY)Fundal Height - 38week sizeSFH- 35 cmSingle foetus Longitudinal lieHead presentationNot engaged.FHS is 160 beats/min, strong and regular.

INVESTIGATIONS Blood for CP – RBC, WBC, & platelet are normal in both count and morphology

Chemical Pathology – Alkaline Phosphatase↑ Infection screening HBs Ag - negative, HCV Ab - negative, Blood for VDRL – non-reactive

HIV screening test – reactive, 1st confirmation test – reactive, 2nd confirmation test – Positive

HIV screening test of the husband - reactive, 1st confirmation test – reactive, 2nd confirmation test – Positive

CD4 count - 284 cells/L (Normal - >400 cells/L)

INVESTIGATIONS

USGDate of present report 2nd July, 2014No. of foetus: SinglePresentation: Head Lie: LongitudinalPlacental Localization: Anterior, upperAmniotic fluid volume: NormalRadiologist Comments Single viable foetus 27 week at EGA

PROVISIONAL DIAGNOSIS

29 years oldG 3, P 2+0at 34+6 weeks of pregnancy with HIV infection and acute gastritis

ANALYSIS OF THE PROBLEM

From 3 Aspects:1. Social Etiology2. Diagnoses – Clinical & Social3. Social Implications

SOCIAL ETIOLOGY

Social Etiology

Predisposing Factors

Enabling Factors

Precipitating Factors

Reinforcing Factors

PREDISPOSING FACTORS

Poverty Husband’s daily income - 5 thousand kyats

Low Education Level passed only the 4th Standard

Poor Health Knowledge not interested in seeking health knowledge

Weak Guardianship d/t the large size of her family needs personality formation and moral teachings

ENABLING FACTORS

Low education Level of HusbandOccupation of HusbandMorality of Husband, Premarital Sexual Exposure,

Unsafe Sex Lack of Premarital Counselling

PRECIPITATING FACTORS

Pregnancy increases HIV infection progression, progression to AIDS and the chance of death.

Nature of her Occupation weakens her health and worsens her condition.

REINFORCING FACTORS

Poor Nutrition does not eat any meat other than small fish.

commonly eats vegetables → low protein diet.

Lack of Family Support Currently, only her husband staying with her

insufficient as family support.

CLINICAL DIAGNOSIS

29 years old, G 3, P 2+0, at 33+6 weeks of pregnancy with HIV infection and acute gastritis

SOCIAL DIAGNOSIS

PovertyPoor education Lack of health knowledge especially reproductive health

SOCIAL IMPLICATIONS

Social Implicatio

ns

Individual Level

Family Level

Community Level

National Level

INDIVIDUAL LEVEL

Psychological Stress others might ignore her socially isolated loss of support from family & friends emotional breakdown fear of opportunistic infections, anticipatory grief, shame, helplessness, and discrimination

FAMILY LEVEL

Increased risk of transmission of HIV from mother to child during pregnancy, birth or lactation

Financial problems Inability to work during pregnancy Increase in expenditure of healthcare and health facilities

Family Burden care given to her during gestation period → take effort and time of family members.

Reduction of care for other children

COMMUNITY LEVEL

Increased risk of transmission Increased workload for doctors and medico-social workers

NATIONAL LEVEL

Decreasing Human resources Increased incidence and prevalence of HIV infected person

Increased workload of health sector

Predisposing factors

Poverty Low Education Level Poor Health

Knowledge Weak Guardianship

 

Enabling Factors Low education Level

of Husband Occupation of

Husband Morality of Husband Premarital Sexual

Exposure, Unsafe Sex Lack of Premarital

Counselling Precipitating factor

Pregnancy Nature of Occupation

 Reinforcing factors Poor Nutrition Lack of Family

Support

 

 

Clinical diagnosis

29 years old, G 3, P 2+0, at 33+6 weeks of pregnancy with HIV infection & acute gastritis

Social diagnosis

Poverty Poor education Lack of health

knowledge especially in reproductive health

Individual Level Psychological stress

 

Community Level Increased risk of

transmission Increased workload

for doctors and medico-social workers

Family Level• Increased risk of

transmission of HIV• Financial problems• Family Burden• Reduction of care for

other children

National Level Decreasing Human

resources Increased incidence

and prevalence of HIV infected person

Increased workload of health sector

Social Etiology

Social Implication

CLINICO-SOCIAL MANAGEMENTS

Mangements

Immediate Managem

ent

Individual Level

Family Level

Long-term Managem

ent

Individual Level

Family Level

Community Level

National Level

IMMEDIATE MANAGEMENTS

Individual LevelPsychological support and counsellingPMCTNutritionTreatment for acute gastritis

Family LevelCounsellingSterilizationARV Prophylaxis to Baby

LONG-TERM MANAGEMENTS

Individual LevelSocial support and ART treatmentRestSafe water and FoodAvoid handling petsSafe Sex

Family LevelHealth EducationPrevention of HIV transmission

COMMUNITY LEVEL

HE about blood transfusion, drug abuse, sexual promiscuity and their disease

HE to sex workers about safe sex Encouraging the community to help patients by giving psychological support

Cooperation and collaboration with social welfare services such as NGOs

NATIONAL LEVEL Promoting literacy Creating job opportunities Promoting national health care services and facilities

National HIV/ AIDS Control Program (NAP) Implementing PMCT programme Surveillance against STD in community Identify missing cases Cooperation and collaboration with INGOs, local NGOs and services

Supervision, monitoring and evaluation

SUMMARY OF THE CASE

A female patient, aged 29, G 3, P 2+0, came to CWH for acute gastritis and AN Care.

HIV testing done as part of the AN Care package - positive result

Admitted to CWH, B Block, Unit 3 on 24th August, 2014 for PMCT.

Her husband tested for HIV - positive. Both - low income, poor educational status and lack of reproductive health education.

SUMMARY OF THE CASE

CD4 count - <350 cells/mm ART treatment Her husband - referred to Tharketa STI Hospital for ART treatment.

Counselling - HIV, PMCT, delivery and infant feeding

THANK YOU

FOR YOUR ATTENTION!!!

ANY QUESTION???