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Clinico Psycho-Social Case(CPC)

Presenter Dr Md Abu Bashar

Junior ResidentCommunity MedicinePGIMER, Chandigarh

ModeratorDr Sonu Goel

Assistant ProfessorSchool of Public Health

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Name Age/Sex Education Occupation

Income Health Status

Gorakh Ram

65/M Matric Retired BSF inspector

35000 Hypertensive recently diagnosed

Bidya Devi 54/M 8th Housewife Nil Type 2 DM

Kairon Devi 87/F Nil Ex-trained Dai

Nil Hypertensive with h/o Stroke(CVA) leading to hemiparesis

Family Profile

SES- UPPER MIDDLE CLASS(II) A/C to UDAY PARIKH SCALE

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Kairon Devi, w/o late Hansraj, 87 yrs old from kheri village of Raipur Rani block of distt Panchkula, Haryanabedridden for 1.5 yrs in her house following attack of stroke in june,2013

Index Case

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Weakness of Right side of body Speech difficulties Unable to stand or walk Pain in right upper and lower limbs with

inability to extend fully

Presenting Complaints

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Was hypertensive for 30 years Was on medications from PGI Health Center

in Kheri and CHC Raipur Rani Sustained a attack of stroke while

performing Puja in evening of 12th June,2013.

Pt fell on the ground and started having tremors.

Subsequently developed partial loss of speech along with right sided paralysis.

History Of Present Illness

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Pt was brought to military Hospital, Chandigarh in their private vehicle next day only

was shown in emergency and got admitted in ICU

Was put on constant monitoring of vitals Was inserted Nasogastric(NG) tube for

feeding as she was unable to swallow and Foley’s catheterization.

History of Present Illness

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shifted to wards from ICU on 3rd day Was administered I.V. Fluids along with

Neurobion injections during stay in ICU Continued to put on NG Feeding in wards

along with IV fluids Was discharged on day 16 of hospitalization Was diagnosed as case of CVA with right

sided hemiparesis Developed UTI during hospitalization and

was given oral antibiotics

History of Present Illness

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Was advised massage and exercises during hospitalization by the physiotherapist

Physiotherapists only told the method of exercises and massage but didn’t performed.

Daughter-in-law performed for some duration(1-2 months) but left due to her ill health

Currently no physiotherapy is being given to the pt

History of Present Illness

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Pt’s family member contacted some traditional faith healers too

Received 5 inj.(content unknown) for cure of paralysis soon after being discharged from hospital

No improvement reported from above therapy

History of Present Illness

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k/c/o hypertension for last 30 years On regular treatment from PGI center at

Kheri On tab. Hydrochlorthiazide 12.5 mg BD Never undergone Lipid Profile, Kidney

Function Tests or ECG Was taking regular NSAIDs(tab. Brufen) for

relief of pain knee joint from PGI center

Past history

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Currently receiving Tab. Ecosporin (150 mg) HS Tab. Atorvas (40mg) HS Tab. Beclofen (10mg) HS Syp. Lactulose (30mg)HS Tab. Atenolol (25mg) ODPrescribed from Military Hospital, Chandigarh Adherence to medications – good( A/c Morisky adherence

rating scale) Was on tab. Hydrochlorthiazide (12.5 mg) BD Before attack Compliance- poor Was regularly taking painkiller (tab. Brufen) for B/l pain knee

joints. known Allergy to any drug- Absent

Drug history

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Brother was hypertensive, died of heart ailment as told by son

Two of the sons are hypertensive No family h/o Diabetes, stroke

Family history

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Non-smoker, Non-alcoholic Vegetarian Have 3 sons & 2 daughter, all alive Was working as trained Dai in the village Religious

Personal History

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Good interpersonal relations in the family As she was a trained Dai, villagers use to come

to her for advice for pregnant women and have good rapport with the neighbours

Basically from Hamirpur distt of HP, migrated 40 years back

Use to attend local meetings and was an active member of Various groups like mahila mandal/SMS

Received training for performing home deliveries in past and use to conduct home deliveries

Social history

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Living in a Pukka House with his second son and his wife

3 rooms in the house with separate kitchen and toilets

ventilation- adequate Lighting- adequate Source of cooking – LPG cylinders Source of Drinking water – filtered water indoor air pollution - Absent

Environmental history

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Passive smoking- Absent Flies – present outside house Mosquitoes and rats – Absent Toilet – western and Indian both

Environmental history

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For minor ailments, family use to visit PGI center at kheri and CHC Raipurani

For major ailments, use to visit Military Hospital, Chandigarh

Currently under treatment from military hospital, Chandigarh

Irregular in visits, last visit 2 months back

Treatment seeking Behaviour

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Pt seems to get affected by disturbances in the family

Feeling concerned for the marriage of her grandson as told by the daughter-in-law

Pt use to recall the days when she use to be a trained Dai and use to give advice to pregnant women in the village

Son and daughter-in-law takes care of her but feel burdened of taking care of her

Psychological Component

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Timing Content of diet Kilo Calories provided

7 AM 1 Cup of TEA + 2 SMASHED BISCUITS

250

9 AM 1 PHULKA+ 1 GLASS MILK 250

1 PM 2 PHULKA+ ½ KATORY DHAL 260

5PM 1 CUP OF TEA + 2 SMASHED BISCUITS

250

9PM 2 PHULKA + 1 GLASS MILK 340

TOTAL 1450

Dietary history(A/c to 24 hrs recall method)

TOTAL CALORY DEFICIT = 1850-1450= 400 kcal

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Pt conscious, orientation to T/P/P Built & Posture - Average , Non-obese, kyphotic spine Pulse- 96/min RR- 16/min BP- 150/90 mm of Hg Temperature – Afebrile Pallor- ++ Icterus, Clubbing, cynosis, lymphadenopathy, edema –

Absent Jugular veins- Not engored Thyroid – not enlarged weight, height, BMI- could not done Arm span- could not be done

General examination

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Oral cavity – Teeth – absent(edentulous), Gums- spongy Tongue-

coated, papilla absent, Tonsils- not enlarged, hygiene- poor

Eyes – vision-right eye 6/18, left eye 6/36 senile immature cataract present in left eye Ptosis of right eye lid Pupil equally reacting to light Ear – wax present, no discharge seen, hearing diminished on both sides

Systemic examination

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Cardiovascular system Inspection – jugular veins not engorged Palpation- apical impulse felt in left 5th

intercostal space Auscultation – S1 S2 Heard, no murmur

heard

Systemic examination

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Respiratory system Inspection – trachea central, right chest wall

lower than left moving equally with respiration

Palpation- no chest wall abnormality felt, no tenderness present

Percussion – resonant note found all over chest wall

Auscultation – normal vesicular breath sounds, Air entry equal on both side, no crepts or rhonchi heard

Systemic examination

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Abdominal examination Inspection – abdominal wall normal in shape with

no scars, moving equally with respiration wrinkles present over abdominal wall umbilicus invertedPalpation – liver, spleen – not enlarged bladder – not distendedPercussion – no fluid thrill or shifting dullness heardAuscultation – bowel sounds present

Systemic examination

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Nervous system – A. Global & Functional assessment – Katz ADL is the most appropriate tool to

assess it. A score of 6 indicates full function, 4

moderate impairment and 2 or less severe functional impairment

Systemic examination

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PT SCORE ON ACTIVITIES POINTS(1 OR 0)

INDEPENDENCE(1 POINT) NO supervision, direct or personal assistance

DEPENDENCE (0 POINT)WITH supervision, direct, personal assistance or total care

BATHING POINTS - 0

(1 POINT) Bathes self completely or needs help in bathing only a single part of body

(0 POINT) Needs help in bathing more than one part of body. Requires total bathing

DRESSING POINTS -0

(1 POINT) Gets clothes from closets and puts on clothes complete with fasteners

(0 POINT) Needs help with dressing self or need to be completely dressed

TOILETINGPOINTS -0

(1 POINT) Goes to toilet, gets on and off, clean genital area without help

(0 POINT) Needs Help transferring to the toilet, cleaning self or uses bedpan or commode

TRANSFERRINGPOINTS - 0

(1 POINT) Moves in or out bed or chair unassisted.

(0 POINT) Needs help in moving from bed to chair

CONTINENCEPOINTS- 0

(1 POINT) exercise complete self control over urination or defecation

(0 POINT) Is partially or totally incontinent of bowel or bladder

FEEDINGPOINTS- 0

(1 POINT) Gets food from plate into mouth without help

(0 POINT) Needs partial or total help with feeding or requires I.V. feed

Katz index of independence in ADL

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Motor system Power – Right upper limb- 1/5 Left UL-4/5 right lower limb- 1/5 Left UL -4/5 Tone- increased tone in right upper and lower limbs Bulk of Muscles- contractures in muscles of upper and lower

limbs Gait – pt unable to walk Reflexes - Superficial reflexes- absent on affected side Deep tendon reflexes – exaggarated on affected

side Sensory system – Normal

Nervous system examination

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Higher mental functions Memory- impaired Orientation – oriented to time/place/person Judgement – intact Speech – hesitancy in word production,

difficulty in articulation, normal fluency

Nervous system examination

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MRI Brain(15/06/13)- finding s/o thromus @ left MCA with multiple anterior ischemic infarcts

Lipid profile(14/06/13) – WNL except raised triglycerides

ECG(6/12/13) – Atrial flutter with predominant 2:1 AV block

HB(14/06/13) – 9 gm/dl LFT, BLOOD COUNTS- WNL

Investigations done

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A 85 old Hindu vegetarian female belonging to 3 member family of upper middle class a/c to Uday parikh scale, k/c/o hypertension for past 30 years currently suffering from right sided hemiparesis with speech difficulties following a attack of stroke in year 2013 alongwith left eye cataract & hearing impairment & mild anaemia

Provisional diagnosis

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Investigations needed Lipid profile Renal function tests Serum calcium & vitamin D3 levels Coagulation profile Dexa scan Mammography and pap smear ECG Routine urine & urine culture

Management at Individual Level

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Drug therapy Continue prescribed medications Tab. Amlodepine (5 mg) 1 tab OD Tab. Fe(100 mg) 1 tab OD Tab. Calcium(500 mg) 1 tab OD Tab. Becosule-Z 1 tab 0D Avoiding NSAIDS Ensuring compliance to medications and

regular monitoring of Blood Pressure

Management at Individual level

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Dietary advice Adding one serving of fruit per day Reducing salt intake Adding vegetables in the diet

Consultations Opthalamology consultation for Sx of left eye

cataract and correction of refractive errors ENT consultation for hearing assessment and

correction by hearing aids and speech therapy physiotherapy consultation for exercises for

improvement of weakness of limbs

Management at Individual level

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Rehabilitation after stroke aims to preserve or improve range of motion, muscle strength, bowel and bladder function, and functional and cognitive abilities. 

Preventive measures for pressure ulcers- frequent change of posture by the care giver

Joint mobility- each affected joint is passively exercised through normal range of motion 3-4 times/d and active exercise of unaffected extremities

Ambulation – patient should be made to stand and walk with support

ADL- activities like moving in bed, turning, changing position, sitting up should be practiced with support from caregaver/s

Management at Individual level

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Screening - All family members should be screened for hypertension and Diabetes

Lifestyle changes & compliance-Those already diagnosed( Son and daughter-in-law) should be compliant to medications along with lifestyle changes like regular exercise, low salt intake, dietary modifications like adding fruits and vegetables in diet and regular follow up

Training- family members should be trained on methods of home based care of the patient

Ensuring physiotherapy – family members may be trained about the various exercises so that they could perform at home too.

Counseling - regarding providing emotional support to the patient

Management at Family level

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Social & Financial Support for elderly National Programme for control of Cancer,

Diabetes, Cardiovascular diseases and Stroke(NPCDCS)

National Programme for healthcare of elderly(NPHFE)

Stroke helplines Creating awareness about prevention of NCDs Sensitization of community towards need of

elderly Rehabilitation measures

Management at Community level

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National schemes- Indira Gandhi National Old Age Pension Scheme-Rs 1000/- month

is given to all citizens below poverty line who are > 60 yrs Varishtha Pension Bima Yojna- will provide monthly pension

ranging from Rs 500 to Rs 5,000 to senior citizens. Annapoorna -10 kgs. of food grains per beneficiary per month are

provided free of cost to those senior citizens who remain uncovered under the old age pension scheme.

Integrated Programme for Older Persons (Plan Scheme) - Financial assistance upto 90% of the project cost is provided to NGOs for establishing and maintaining Old Age Homes, Day Care Centers, Mobile Medicare Units and to providing non-institutional services to older ones.

Income tax rebate upto an income of Rs. 2.5 lakhs p.a. for >60 yrs and upto 5 lakhs for >80 yrs

Social & Financial support

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State initiatives Old age Samman Allownce scheme- pension

@1000/- month for all residents of Haryana >60 yrs having income<2 Lakhs/annum

Widow Pension Scheme – pension @1000/-month for women>18 yrs & having income<2 Lakhs/annum

Social & financial support

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NPCDCS

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Tobacco, alcohol, unhealthy diet ,physical inactivity, high salt intake, high BP & obesity are major risk factors common to many NCDs.

Keeping in view that there are common preventable risk factors for Cancer, Diabetes, CVD & Stroke, GOI initiated it during 2010-11

Focus of NPCDCS is on promotion of healthy life styles, early diagnosis & M/m of diabetes, HTN, CVD including stroke & common cancers

Implemented in 100 pilot districts across 21 states during 2010-12.

NPCDCS

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Activities consists of opportunistic screening of persons above the age of thirty years for diabetes and hypertension ,at the point of primary contact with any health facility

Each District hospital will have regular NCD clinic for screening, management , and counseling & awareness generation for NCDs

6-10 bedded Cardiac care Unit(CCU)/ICU would be established in at least 25% DHs.

The districts will be supported with certain essential drugs including TPA for stroke patients.

NPCDCS

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NPHCE is an articulation of the International and national commitments of the Government as envisaged under the UN Convention on the Rights of Persons with Disabilities, National Policy on Older Persons & Section 20 of “The Maintenance and Welfare of Parents and Senior Citizens Act, 2007”

The Vision of the NPHCE are: To provide accessible, affordable, and high-quality long-

term, comprehensive and dedicated care services to an ageing population;

Creating a new “architecture” for Ageing; To build a framework to create an enabling environment

for “a Society for all Ages;” To promote the concept of Active and Healthy Ageing.

National Programme for Health Care of Elderly(NPHE)

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Community based PHC approach including domiciliary visits by trained health-care workers

Dedicated services at PHC/CHC level including provision of machinery, equipment, training, additional human resources, IEC etc.

10 bedded wards for elderly at District Hospitals Strengthening of 8 Regional Medical Institutes to provide

dedicated tertiary level medical facilities for the elderly, introducing PG courses in geriatric medicine, and in-service training of health personnel at all levels

IEC using mass media, folk media and other communication channels to reach out to the target community

Continuous M & E of the Program & research in geriatrics Promotion of public private partnerships in geriatric health-care Mainstreaming AYUSH Reorienting medical education to support geriatric issues.

Strategies for achieving objectives of NPHE

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These helplines are available in different cities by different numbers

The goal is to get the stroke victim to a hospital as quickly as possible to confirm the diagnosis because every minute is important.

In Mumbai, in year 2006, a group of neurologists launched an 24 hr helpline by name” ambulance access to all” in which anyone having symptoms of stroke can contact on the helpline to be picked by nearest ambulance for treatment

The ambulance is equipped with life saving equipment including defibrillator, ECG, cardiac monitor, ventilator and resuscitation kit. 

PGIMER, Chandigarh too launched a stroke helpline in year 2014 to help patients with possible attack of stroke

Stroke helplines

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THANK YOU