University of Medicine Mandalay

Department of Preventive and Social Medicine

Clinico-Social Case On Paediatrics

Final Part I M.B.,B.S (7/2016)

Urban Posting Group 2 (D)

RN 172-194
Supervisor Dr. Su Yee Toe
Dr. Nay Oke Khaing
Dr. Mya Myat Chal Myint
Presented by Nay Myo Htet
I. Personal Characteristics

-May Phyo Thu, a 9yrs old girl, 3rd standard

-The youngest child of U Win Aung and Daw Nwe Nwe Soe
-From Kan-lae-Gyi village, Kawlin township
-referred from Kawlin Hospital to M3 550-bedded Mandalay Children
Hospital on 27th November,2016 .
Chief compliant
- fever and cough for 20 days,
- diarrhoea for 10days,
- abdominal pain for 1wk

History was taken from her aunt Daw Moe Thi and her father U Win
Aung.
II. Summary of Relevant Social and Community
Aspect
1. Personal History
-NSVD at home with traditional birth attendant
-Since childhood, she has health problems such as diarrhea,
epistaxis and fever
-Her mother died when she was 1yr and 7mth old
-cared by her father and her aunt
2. Family history
-Extended or joint family
-size of family - 6 members
-Head of family - U Win Aung
Family Tree
U Aung Chi Daw Myint Aye
80yrs 65yrs

U Win Aung Daw Nwe Nwe Soe Daw Moe Thi U Lin Aung
45yrs 45yrs 43yrs 35yrs

May Phyo Thu

9yrs
- Father passed 10th standard, a farmer
- has habits of smoking, alcohol drinking and betel chewing.
- known that he has retro at 5th
December,2016 at MCH - no history of TB.

- Mother passed away at 2005.

- Cause of death - unknown.
- symptoms - cough, diarrhea, fever and breast abscess.
- her sister - 11yr old, 5th standard
- known that she is retro positive at 5th December,2016 at MCH - no
history of TB

- her grandfather - 80yrs old - had

stroke last three years ago - now having
hemiplegia

- other family members - healthy - they

havent been screened for TB and HIV
3. Social Environmental History

- all members - Burmese, Buddhists.

- housing- wooden type, 1 storeyed house
- Floor space per person - 57sqft
- Lightening - good
- ventilation - bad
- Kitchen - attached to the house
- Water - for drinking is used from shallow well, not boiled,
for domestic use is from tube well
- Latrine - septic tank
- Refuse - disposed in manure pit
- Rats, mosquitoes and flies - present
- Transportation roads are bad.
- Income - about 150000 kyats per month.
- Income - not enough
- have financial problems
4. Health facilities
- Kawlin Township Hospital - 2miles away from the village.
- treated her with a quack in the village before admitting to the
hospital

5. Nutritional status of the child

- Breast feeding - unknown
- Weaning diet - unknown
- Dietary history before illness - fed 3times a day, include meal,
vegetables everyday
III. Summary of Clinical Aspect
1. History taking
- not previously well
- had fever off and on last 2 months ago.
- had diarrhea last 2 months ago.
- now, suffered remittent low grade fever for 20days
- evening rise in temperature, no chills
- no vomiting
- cough for 20 days, yellow sputum about 1 spoon, no
haemoptysis - no chest pain
- had diarrhea for 10days
- no blood stain in the stool,
- suffered abdominal pain for 1week at epigastrium
- had loss of appetite and loss of weight
- admitted to Kawlin Hospital for 1 wk
- treated her with antimalarial drugs such as artimeter and artisunate
- her condition become worse and referred to the 550-bedded MCH.

Past Medical and Sugical History

- no history of hospitalization
- immunization history-complete
2. Clinical Examination

- General condition - fair, not dysponoeic, not irritable, thin for her age
- Temperature is raised
- Oral thrush absent
- BCG scar is present
Systemic Examination
- CVS - pulse rate is 100/min
- BP - 120/70 mmHg
- Heart sound - normal first heart sound followed by second
heart sound
- Respiratory system - Respiratory rate is 28/min. VBS, added
sounds and cerpitations (-)
- Abdomen is soft.
- Liver and spleen - not palpable.
- cervical, Axillary, Inguinal lymph node englargements.
3. Provisional diagnosis is retro positive with pulmonary tuberculosis.

4. Investigations
27.11.16 - Haematological report
WBC - normal, Hb - reduced, platelet - normal
ESR - 15+
MP - not seen
ICT malaria - negative
Widal test - Negative
28.11.16 - USG (Abd) intraabdominal lymphadenopathy
CXR-NAD
29.11.16 - HIV (Ab-NHL) positive
HBs Ag-Negative
HCV Ab-Negative
GAS microscopy specimen for TB - 2+
Gene Expert result - MTB detected medium
Rif resistance not detected
11.12.16 - tuberculin test - negative
21.12.16 - Indian ink preparation (C.S.F)
No cryptococus
-CD4 count is still pending.
5. Diagnosis
- Retro positive with pulmonary tuberculosis.
 Social eitology Social Implication

Personal factors
IV. Problem Analysis Individual
-lack of health -social problems
knowledge -depression
-child -poor health
-passive smoker
Family factors Family
-retro contact -risk of infecting others
-lack of awareness of -increase burden on
disease family
Retro+ with pulmonary
Sociodemographic tuberculosis
Community
factor
-increase TB cases
-low income
-increase retro cases
-large family size
-increase workload for
-overcrowded
hospital
Service factors
-Poor access and National
utilization to health -Detoriation of human
care services resources and decreased
productivity
-increase burden of TB
and retro
V. Discussion of Possible Solution for Patients

Immediate Managemet
Clinical
-Anti TB drugs
Ethambutol 300mg, Isoniazid 150mg, Rifanpicin 225mg,
Pyrazzinamide 450mg
-ART
Lamivudine and Zidobudine
-Paracetamol 250mg qid
-Zytee gel
Long term Management
Individual level
- regular taking of drugs
- regular follow up
- good nutrition and hygiene
- Morale support and awareness of her health problem

Family level
- to take care of the patient
- HE to increase awareness of pulmonary TB and HIV and how to
prevent
- to do screening tests on other family members
Community level
- giving knowledge about TB and HIV
- HE about transmission
- Collaborative TB and HIV services
- Provision of counselling services

National level
- HE through mass media
- Implementing ART services
- Implementing STOP TB strategy up to gross root level
- Making adequate health facilities and services to the village