2. Contoso
S u i t e s
Socio-Demographic Details:
Name: Mrs. Dhakshayani (alias Padma)
Age: 47yrs, Sex: Female
Religion: Hindu
Caste: MBC (Gounder)
Education: Illiterate
Occupation: Housewife
Address: House no 33, 2nd Street, Kazhagaagraharam.
Nearest Health Facility: CHC Karikalampakkam ( approx. 5kms )
2
3. Contoso
S u i t e s
COMPLAINTS
CHIEF COMPLAINTS: No complaints as of
now.
HISTORY OF PRESENTING ILLNESS:
- She is a known case of Hypertension *treatment from1yr on regular basis.
- No History of Headache/Giddiness
- No History of Defective Vision.
- No History of Pedal oedema and Puffiness of face.
- No History of any weakness of limbs.
3
4. Contoso
S u i t e s
When She went for the regular check up following
surgery, she was found to have high BP and was started
on T. Telmisartan 20mg BD.
She checks her BP every 6 months but takes medication
regularly.
History of
Diagnosis and
treatment of
present illness.
4
PAST HISTORY
Fibroid uterus – 2 years back operated in
private Clinic (Dr. Shanthi Michael)
Not a known case Of DM, TB.
5. SOCIO-
ECONOMIC
HISTORY
Ration Card colour: Pink
Socio-economic status: Above Poverty
Line.
Husband’s Income: 10,000 Rs/month.
A member of Self Help Group.
Have Debts.
Relationship with relatives and neighbours
is good.
6. Contoso
S u i t e s
Family
History
6
Type of family: Nuclear.
No. of Family Members: Four ( Husband, herself
and her two sons).
** Her Husband suffers from the hypertension.
*No history of DM, TB or other illness with any of
the family members.
7. Contoso
S u i t e s
Dietary-History
24hr Recall
Usual Dietary Intake
MORNING: 1 CUP UPMA. (270KCAL)
1 CUP TEA. (75KCAL)
Chutney: 15kcal
AFTERNOON: 1 BOWL RICE (240KCAL)
FISH CURRY 320KCAL
NIGHT : FISH CURRY 320 KCAL
IDLY *4 nos 300KCAL
# Non-vegetarian.
She is not taking any snacks.
Total calorie intake: 1540kcal.
7
8. Nutritional History
Weight : 76kg.
Height: 159cms.
BMI = Weight/height in m2
= 76/(1.59)2 Kg/m2
= 30.1 kg/m2 (obese class 1)
• BMI between 25 to 30 falls under overweight
• BMI > 30 is obesity.
• Waist to Hip ratio. Waist: 95, Hip: 104 . Waist/hip= 95/104= 0.9
• Waist to hip ratio more than 0.85 indicates abdominal fat
accumulation.
• Nutritional assessment She is normal sedentary women. As her
diet Indicates she is taking diet of less than 1900Kcal it is not
adequate.
• Her Diet lacks Green leafy vegetables and fruits.
9. Contoso
S u i t e s
Environmental
History
Type of House: Pucca , self owned.
Lighting and Ventilation: Adequate.
Kitchen: Inside the house.
Fuel used for cooking: LPG
Water Supply: Corporate Water, twice a day, No
purification methods.
Availability of Latrine: Yes.
Collection of waste: Inside the house in dustbin.
Disposal: Dumping on the open area.
9
10. Contoso
S u i t e s
General & Systemic Examination
General Examination: On examination, no sign of Pallor, Icterus, Cyanosis, clubbing, Lymphadenopathy or
Edema.
Vital Sign: Respiratory: Regular, equally heard in all areas.
Radial Pulse: felt
Rate: 86beats/min. Rate, rhythm, volume:: Normal
Blood pressure:: Lt upper arm: 170/88 & 178/92 mmHg
Rt upper arm: 158/92 mmHg
Average:: 178/90
Systemic Examination::
Abdomen: soft, non tender.
CNS: no neurological deficit.
CVS: Position of trachea:Central Shape of chest:Bilaterally symmetrical Apical Impulse:Not seen.
RS: normal vesicular sounds are heard.
10
11. PROVISIONA
L
DIAGNOSIS
As her Blood pressure levels indicates she is a
Stage 2 Hypertensive patient.
Stage 2 Hypertension, systolic>160mmHg and Diastolic>100mmHg
12. PROBLEM GOAL STRATEGY
OVERWEIGHT REDUCTION IN WEIGHT 5-7KGS LOW SODIUM AND LOW FAT DIET
ALTERED NUTRITION AND LESS
PHYSICAL ACTIVITY
TO BRING DOWN THE BLOOD PRESSURE TO EDUCATE PATIENT TO CHOOSE LOW
FAT FOOD AND INCLUDE GREEN LEAFY
VEGETABLES AND FRUITS.
TO ENCOURAGE HER FOR DAILY
PHYSICAL ACTIVITY LEVELS.
MANAGEMEN
T
REGULAR CHECK-UPS AT LEAST ONCE IN
EVERY THREE MONTHS.
