Upload
abu-bashar
View
36
Download
1
Embed Size (px)
Citation preview
Presenter Dr Md Abu Bashar
Junior ResidentCommunity MedicinePGIMER, Chandigarh
ModeratorDr Sonu Goel
Assistant ProfessorSchool of Public Health
4/19/2015 1
Name Age/Sex Education Occupation Income HealthStatus
GorakhRam
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
4/19/2015 2
SES- UPPER MIDDLE CLASS(II) A/C to UDAY PARIKH SCALE
Kairon Devi, w/o late Hansraj, 87 yrs old from kheri village of Raipur Rani block of disttPanchkula, Haryanabedridden for 1.5 yrs in her house following attack of stroke in june,2013
4/19/2015 3
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
4/19/2015 4
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.
4/19/2015 5
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.
4/19/2015 6
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
4/19/2015 7
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
4/19/2015 8
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
4/19/2015 9
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
4/19/2015 10
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
4/19/2015 11
Brother was hypertensive, died of heart ailment as told by son
Two of the sons are hypertensive
No family h/o Diabetes, stroke
4/19/2015 12
Non-smoker, Non-alcoholic
Vegetarian
Have 3 sons & 2 daughter, all alive
Was working as trained Dai in the village
Religious
4/19/2015 13
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 mahilamandal/SMS
Received training for performing home deliveries in past and use to conduct home deliveries
4/19/2015 14
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
4/19/2015 15
Passive smoking- Absent
Flies – present outside house
Mosquitoes and rats – Absent
Toilet – western and Indian both
4/19/2015 16
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
4/19/2015 17
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
4/19/2015 18
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
4/19/2015 19
TOTAL CALORY DEFICIT = 1850-1450= 400 kcal
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
4/19/2015 20
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
4/19/2015 21
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
4/19/2015 22
Cardiovascular system
Inspection – jugular veins not engorged
Palpation- apical impulse felt in left 5th
intercostal space
Auscultation – S1 S2 Heard, no murmur heard
4/19/2015 23
Abdominal examination
Inspection – abdominal wall normal in shape with no scars, moving equally with respiration
wrinkles present over abdominal wall
umbilicus inverted
Palpation – liver, spleen – not enlarged
bladder – not distended
Percussion – no fluid thrill or shifting dullness heard
Auscultation – bowel sounds present
4/19/2015 24
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
4/19/2015 25
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
DRESSINGPOINTS -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
FEEDING (1 POINT) Gets food from plate (0 POINT) Needs partial or
4/19/2015 26
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 sideDeep tendon reflexes –
exaggarated on affected side Sensory system – Normal
4/19/2015 27
Higher mental functions
Memory- impaired
Orientation – oriented to time/place/person
Judgement – intact
Speech – hesitancy in word production, difficulty in articulation, normal fluency
4/19/2015 28
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
4/19/2015 29
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
4/19/2015 30
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
4/19/2015 31
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
4/19/2015 32
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
4/19/2015 33
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
4/19/2015 34
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
4/19/2015 35
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
4/19/2015 36
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
4/19/2015 37
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
4/19/2015 38
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.
4/19/2015 40
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.
4/19/2015 41
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.
4/19/2015 42
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.
4/19/2015 43
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
4/19/2015 44