Clinico Psycho Social Case Review

Case of a child under

5years

Department of Community and Family Medicine

AIIMS Bhopal
Case presentation by
• 21. Ayush Bhargava
• 22. Suraj Singh babar
• 23. Yash Bulbule
• 24. Cherukuri Shreya
• 25. Harsha Vardhan
CONTENTS
 • Psychosocial aspects
• Demographic data
• Environmental
Index Case details assessment
Family details • Clinical examination
Pedigree Chart
• Clinical diagnosis
Socio Economic
status • Family diagnosis
• Clinical case history • Web of Causation
• Dietary history • Advices and
• Immunisation history interventions

• Developmental history
Index Case
details
• Age : 6 months
• Gender : Male
• Informant : Mother
• Information : Reliable
Family details
Head of Family
• Age : 65years
• Gender : Male
• Religion : Muslim
• Address : E/6 Arera colony, Sai baba nagar, Bhopal
Family composition
Type of family : Joint family
Total family members : 7
Pedigree Chart
 Relation to Educational
Age Sex Occupation Income
HOF Status
Retired govt.
1 HOF 65 years Male Graduate ₨4,000
Job

2 Son 44 years Male 12th Pass Business ₨20,000

Daughter in B.Com
3 41 years Female Teacher ₨15,000
law Final year
B.Com
4 Grandson 25 years Male Business ₨20,000
Final year
Grand B.Com
5 23 years Female House wife -
daughter Final year

6 Grandson 21 years Male B.Pharmacy Student -

Great
7 6 months Male - - -
Grandson
Socio Economic Status

• Score
Occupation of HOF - Retired government Job 1
Education of HOF - Graduation 6
Total income of the family - Rs.59,000/- 6
Total Score : 13
The Family belongs to Lower Middle Class as per Modified
Kuppuswamy Scale
Clinical Case History
• Chief Complaints
The child has no chief complaints at the time of our visit.

• History of Presenting illness

No HOPI
• Past history
No medical and surgical history
No history of trauma and hospitalisation

• Family history
No significant family history
No history of any familial disorder
• Mother’s Obstetrics history

Parity - 1
No of live births - 1
No of Abortions - 1
• Birth history
Ante natal history
. Conception was spontaneous and Pregnancy was detected by UPT
kit at home and confirmed by USG 1month after conception
. It was a planned pregnancy
. Non Consanguineous marriage
. Pregnancy was registered in a private hospital
. Total number of ANC visits done were 8; once in every month
. Total of 4 USG’s were done and there was no placental insufficiency,
any abnormality, any complications in growth of the baby
 . Hb levels were normal and her Blood group is A’+’ve
. No history of gestational diabetes mellitus, hypertension, any
infection, hypothyroidism
. Total weight gain in pregnancy was 12-15kg from 45kg to 60kg
. No antepartum hemorrhage
 Ante natal history
1st trimester
. One USG is done to confirm the delivery date and one NT NB
scan at 11 weeks of gestation
. Iron, Folic acid supplements started when pregnancy was
confirmed
. 1st dose of TT vaccine was given when pregnancy is
confirmed
. 2nd dose of TT vaccine was given after 4weeks of first dose
. No history of Fever with Rash, Jaundice, Radiation exposure,
any UTI’s, per vaginal bleeding, abdominal pain, increased
urination frequency
 2nd trimester
. Quickening felt at 5th month of gestation
. Target Scan and Growth Scan were done and there is no IUGR
. Calcium supplements were started with IFA supplements being
continued
. No history of easy fatiguability and general weakness
. No history of headache, polyuria, burning micturition, back pain
and leg cramps, skin changes
. No history of per vaginal bleeding, pre-eclampsia, eclampsia
 3rd trimester
. Increased perception of fetal movements
. Calcium and IFA supplements were continued till the end of
pregnancy
. No history of Per vaginal bleeding, headache, polyuria, burning
micturition, back pain and leg cramps, skin changes
. No history of easy fatiguability and general weakness
 Natal history

. First by birth order

. Pregnancy was Full term and was Cesarean section at
private hospital
. Child cried immediately after birth
. Birth weight was 3.9kg
. There were no complications at birth
Post natal history

. Breast feeding was started within an hour after birth

. No problem in feeding
. No NICU admission after birth
. Discharged after 2 days of delivery
Feeding Practice
• No pre lacteal feeds were given, Colostrum was given
• The baby is exclusively breast fed 4-5 times a day
• Duration of the feed is for 10-15 minutes
• Mother has less milk production
• Stage 1 Dexolac milk is also given for 4-5 times a day after each
breast feed as advised by the physician
• No animal feeds were given
Immunisation history
• As per the informant immunisation is done till date as per the
national immunisation schedule
• BCG scar is present
• At Birth - BCG, HBV, OPV-0
At 6weeks - OPV-1, Pentavalent-1, Rotavirus vaccine-1,fIPV-1,
PCV-1
At 10weeks - OPV-2, Pentavalent-2, Rotavirus vaccine-2
At 14weeks - OPV-3, Pentavalent-3, Rotavirus vaccine-3,fIPV-2,
PCV-1
Developmental history

Milestone expected at this

Domains Milestone attained Remarks
chronological age

Gross Motor Rolls from Prone to Supine Rolls from Prone to Supine

• All the milestones are

Fine Motor Uni dextrous Reach Uni dextrous Reach attained as per
chronological age

Recognises mother, Likes Recognises mother, Likes

Social
and Dislikes and Dislikes
• There is no developmental
delay

Babbles Monosyllables (ba, Babbles Monosyllables (ba,

Language
da, ma) da, ma)
Personal history
• Hygiene : Bathing once daily
• Nails were cut regularly
• No habit of Pica
• Child doesn’t plays in dirt
• Child wears chappals
• Overall appearance of the child : Clean
• Bowel movements - (2-3 times a day)
• Bladder movements - (6-7 times a day)
Dietary history
• The child is exclusively milk fed
• The child is breast fed for 4-5 times a day for 10-15 minutes each
feed
• As advised by the physician, the child is also given Dexolac milk
4-5 times a day after each breast feed
Clinical Examination
General Physical Examination
• Examination is done when the child is conscious and afebrile and the child
is playful and active
• Vitals : PR : 90bpm, normal rhythm and volume
Respiratory Rate : 32 breaths per minute, Thoraco-abdominal
No Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Pedal oedema
Anthropometry

Measurement Normal Value Inference

Length 68cm 67.6-71.6cm

Weight 8kg 7.9-9.7kg

All the parameters of

Head circumference 43cm 42-43cm growth of the child are
normal

Chest circumference 40cm 37-41cm

Mid arm circumference 14cm 12-15cm

Head to Toe examination

Examination Present condition

Hair Normal

Fontanelle Absent

Eye No bitot spots

Oral Cavity Hygienic

Scurvy signs Absent

Rickets signs Absent

Nails Normal
Systemic Examination

System Inference

S1,S2 heard
CVS
No murmurs heard

Normal Vesicular and Bronchial

RS breath sounds heard
No abnormal breath sounds heard

CNS No significant findings

No dilated veins and no

Abdominal
organomegaly
Family Health Study
Psycho Social Assessment
• The family is socially interactive and has a good relationship
among them
• Co-operative during history taking
• Not facing any social problems with their neighbours
• The family is accepted in the community
• The family participates in festivals, marriages and other social
activities
Environmental Assessment
Internal environment
House Plan
• Type of house : Pucca
• Total no of rooms : 4
• Overcrowding : No (based on persons
per room criteria)
• Ventilation : Inadequate
• Light: Artificial light - Adequate
House
• No mosquito breeding sites in the
house
• No rodents inside the house
• There are 3 pet cats in the house
• No fly breeding sites in the house
Kitchen
• Seperate kitchen
• Floor type : Tiles
• Clean
• Covered the stored cooked food
with a lid in a refrigerator
• Covered the stored uncooked
food with a lid
• Fuel used : LPG
• Smoke outlet : Window
Latrine
• Own latrine
• Western type
• Water seal is present
• Water supply is present
• Hygienic
• Ventilation - Adequate
Water Supply
• Continuous water supply
• Source of drinking water : Bhopal municipal corporation from
Lake
• Source of water for other purposes : Bhopal municipal
corporation from Lake
• Storage of drinking water : Pots
• Purification technique : Boiling and filtering into pot using a
sieve
• Method of drawing water for drinking from the container : Glass
using hands
• No mosquito breeding in stored water
Garbage disposal
• Garbage is stored in a closed dustbin just outside the house
• It is disposed outside the house via the municipal garbage vehicle
• The garbage is disposed once in every 2days
External environment
• Closed drainage
• No mosquito breeding sites
• No fly breeding sites
• No Cattle reared nearby the house
• No sewage outside the house
• No garbage dumping outside the house
Knowledge, Attitude and Practice (KAP)
Knowledge
Question Response from mother Inference
Yes, if not being able to gain
What is under-nutrition? weight is an undernourished
child She knows that it is red flag,
but doesn’t know what should
How do know if your child is If the child is weak and not the ideal weight for age
undernourished? able to gain weight

What are the complications if There will be fevers and She knows that under
a child is under-nourished? diarrhoeas nourishment can cause some
health problem
Attitude
Question Response from mother Inference

I feel that breastfeeding Strongly agree

should be the exclusive
method of feeding for the
first six months
The mother has better
I believe that vaccination of Strongly agree attitude towards her child
the newborn is crucial for healthcare
their long-term health

I think that it is important to Strongly agree

monitor the baby’s weight
regularly
Practice
Question Response from mother Inference

Did your first child received Yes

the recommended
vaccinations after birth?
The mother knows the
Do you have transportation Yes importance of the child’s
to healthcare facility for healthcare and is having
your baby’s checkups? good practice towards it
Did you save money or set Yes
aside funds for your child
health?
Did you practice exclusive Yes
breastfeeding for your child
till now?
Clinico Social diagnosis
• A 6 month old boy living in a joint family of lower middle class
(III) socio economic status being healthy and completely
immunised.
The Child being normal in all developmental and nutritional
aspects
Family diagnosis
This is a muslim joint family consisting of 6 members belonging
to lower middle class (III) socio economic status with all their
family members apparently healthy.
• There is no adequate ventilation for the house.
• There are 3 pet cats in the house.
Advice and interventions
For our index case we advised the following
• Take the next vaccination on time
• Start weaning at an appropriate age possibly around next
month which can include cow milk, mashed fruits, oat meals,
green leafy vegetables
Family Advices
• Visit PHC’s regularly for the available medical facilities
• Maintain good hygiene, clean the house frequently
• Prevent the cat from going near the child’s place