Clinico-Social Case Presentation

Dr . Sudha bala
 Identification data
Name- Shoba
Age-14yrs
Sex- female
Education- high school
Religion- Hindu
Occupation- school dropout
Residence- Uppuguda near railway track
Type of family- Nuclear
Number of family members-5
 CHIEF COMPLAINT
Vomiting and loose motions -1day
Vomit-whatever consumed, foul smell,
10 times, projectile, no diurnal variation.
Preceded by nausea and headache.
Stool-watery, copious , foul smelling,8 times,
Low grade fever ,not associated with
abdominal pain , no mucus and blood.
 Family history and Past history
No similar c/o in other family members
h/o ice cream intake (roadside vendor) the
previous day
Past h/o- typhoid 2 years back
No h/o outstation travel and attending
marriage/parties.
 Family composition
Father 45Yrs Illiterate Painter Rs.2000
Mother 40Yrs Illiterate cook Rs.3000
Elder son 20Yrs high school Immunisation
complete
Younger son 12Yrs Middle school
Immunisation complete
Total family income- Rs.5000/month
 Socio-economic and
Socio-environmental
Socioeconomic class(Modified Kuppuswamy) :
Upper lower class- score 9
Socio -environmental factors -
Housing- pucca , rented (Rs2000).
total area- 6x6 ft
1 room, separate kitchen, uses kerosene stove.
Ventilation adequate with Cross ventilation .
 Socio-environmental cont
Water supply municipal water , boiling and
straining, stored in steel vessels(lid) .
Personal hygiene-washing hands without soap
before food and after defecation
Solid waste disposal GHMC
Sanitary latrine- water seal type with
squatting commode. Separate bathroom .
Drain underground system
Vector breeding sites present
No pet animals
 Socio cultural factors
Health seeking behavior - Approach RMP,
considers this present situation as a result of
cold air.
Nutritional factors:
Mixed diet
No food fads and food taboos
 Nutritional assessment
Height-148 cms
Weight -28 kgs
Height for age- normal
weight for height-low
Nutritional status-wasted
Interpretation acute malnutrition
(water-lows classification)
 Dietary intake of study subject by
24 hour recall method
Breakfast 1chappati, 1/2katori dal 200cal

lunch 1cuprice ,1 chappati, 405cal

1/2cup vegetable gravy

dinner 1cup rice 420cal

1/2cup chicken

Total calories 1025cal

Calorie deficit 1175cal

 GENERAL EXAMINATION
Conscious,coherent with increased thirst.
No signs (PICCLE)
Sunken eyes
Skin pinch test- retracts immediately .
Tongue moist and coated
BP-100/70 mm of hg (lying down)
PR-98/min Normal rate and low volume
Respiratory system-NAD, GIT-NAD
Urine output normal.
Not observed any change in weight
 CASE SUMMARY
A 14 yr old female, school dropout from urban
slum belonging to upper lower class with
overcrowding, poor personal hygiene,
inappropriate food practices and wasted
growth had Acute Gastroenteritis (24 HRS)
short duration onset with symptoms of severe
dehydration(decreased urine output and
giddiness)for which she was admitted and
now presently shows improvement of
symptoms.
 DIAGNOSIS
PROVISIONAL DIAGNOSIS -Acute gastroenteritis
with severe signs of dehydration.
Differential DIAGNOSIS Acute gastroenteritis
associated with food poisoning of infective origin
(Bacterial)
SOCIAL PATHOLOGY- poverty, illiteracy, acute
malnutrition, poor personal hygiene and intake
of road side food
SOURCE OF INFECTION- ? probably food-borne
FAILURE LEVEL
Health promotion, Early diagnosis and
 MANAGEMENT
Investigations
Treatment Immediate and maintanance
Health education
 ACTIONS
Individual level
Family level
Community level
National level
 THANK YOU