Sughandha, a 4 year 8 month old girl, presented with a 3 day history of cough and fever. She lives in a rural area in a large joint family with inadequate sanitation and hygiene. On examination, she had a pulse of 130/min and was diagnosed with upper respiratory tract infection. Her family lives in poor conditions with open defecation and untreated water. Recommendations included treatment for her infection and improving her family's living conditions, hygiene, diet, and access to healthcare.

2. CLINICO-PSYCHO-
SOCIAL CASE REVIEW
OF AN UNDER FIVE
CASE
BY :
AKANSHA CHAUDHARY - 4
ASHWANI PANDEY-18
AYUSH MISHRA-21

3. DEMOGRAPHIC DATA
• Name- SUGHANDHA
• Age- 4 years 8 Month
• Sex- Female
• Religion- Hindu
• Father’s name & Age- Guddu Ram 28yrs
Mother’s name & Age- Prabhawati Devi 25yrs
• Address- Wabhanpura, Phulwarisharif,Patna

4. Family profile
• Type of family-
THREE
GENERATION family
• Total members- 9
• 4 children in family
• Habitation- Rural
PEDIGREE

5. Family profile
cont….
EDUCATION:
Father- 8th standard
Mother- 8th standard
OCCUPATION:
Father- Driver
Mother- ASHA worker
FAMILY INCOME:
Guddu Ram=2000/-
Prabhawati Devi=5000/-
Total 7000/-

6. Family profile
cont….
• SOCIOECONOMIC STATUS:
According to Kuppuswamy’s Socioeconomic Status
Scale (Modified)-
1.Education Score (middle school ) = 3
2.Occupation Score (semi-skilled) = 3
3.Income Score = 3
Total Score= 9
Socioeconomic Class- Upper Lower

7. Family profile
cont….
 LIVING CONDITIONS:
-semi pukka house with 3 living room,
• NO bathroom; toilet; kitchen
• Food cooked in veranda on chullah .;area accessible to children
• Defaecation in open space.
• Natural ventilation- inadequate
• Natural lighting- inadequate
• Artificial lighting source- Electricity, kerosene lamp
• General cleanliness of rooms- inadequate
• Overcrowding –
• Room wise –present
• Social –absent
• Area wise-?

8. Family profile
cont….
• Source of water supply- hand pump(35feet)
• Storage utensils- uncovered
• Refuse disposal:
• -thrown near the house
• Water logging in nearby areas & open drains
• Personal hygiene:
• Bathing habits- daily
• Nails-unclean
• brushing teeth- daily (once)
• Hand washing practices: after defecation-ash/mud
• No handwashing before cooking or taking meal
•

9. Family profile
cont….
• Guddu Ram father of Sugandha is alcoholic and tobacoo
chewer.
• Amount of alcohol intake =150ml .
• Frequency= Daily .
• Amount of tobacco intake=3-4 pack /per day.
• No contraceptive measures taken

10. Chief complaints
• Cough- 3 days
• Fever- 3 days

11. History of present illness -
COUGH
• Duration 3 days
• Gradual onset
• Brassy in character
• No whooping
• Productive in nature
• progressive increase in
frequency and severity
• Initially 5-6 times a day
throughout the day.
• No precipitating factor
• Aggravating factor- lying
down
• Relieving factor –sitting
,drinking water
• No diurnal variation
• Accompanied with
running nose.
• No associated pain

12. History of present illness -
COUGH
- Sputum
- yellow in colour
- Amount scanty
- No foul taste or odour
- No blood present

13. HISTORY OF PRESENT
ILLNESS cont.
FEVER-
- Duration 3 days
- Acute in onset
- Remittent in character
- Frequency 1-2 times a day
- Progressive increase in intensity
- Initially mild now moderate (101F)
- Accompanied with rigours
- No chills
- Relieved on medication

14. PAST HISTORY
• Similar episodes of fever and cough in past
• No history of – Pneumonia, Tuberculosis, Malaria, Kala-azar,
Jaundice, Asthma
• No past surgical history

15. PERINATAL
HISTORY
• Birth Date- 7 September 2010
Pregnancy was not booked
ANC
• No antenatal care was given.
• No IFA tablets taken
• TT vaccine administered
• Indiscriminate use of drugs for headache ,vomiting etc
• No USG
• no radiation exposure

16. PERINATAL
HISTORY
• First trimester- suffered from hyperemesis
gravidarum
• Rest trimesters uneventful
• Labour was uneventful
• Normal vaginal, term delivery at PHC, Phulwarisarif
ON 7TH SEPTEMBER 2010

17. PERINATAL HISTORY cont.
• Immediate postnatal & neonatal periods were uneventful
• Cried just after birth
• Birth weight- 3 kg
• Breast fed within 1 hr

18. DEVELOPMENTAL
MIESTONEs

19. GROSS MOTOR MILESTONES
• Started sitting at age of 6 months(6-8months )
• Climbed upstairs at age of 9months (10 months )
• Started walking at age of 13 month (12-15 month )
• started jumping and walking with both legs at age around
2year(2year)
• Started hopping and skipping step on coming downstairs at age of
4year

20. FINE MOTOR MILESTONE
• Started holding objects at age of 4month(3 month)
• Stated holding objects with thumb at age of 9 month (7-12 month
)
• Started eating by it self at age of 17 month (15 month )
• Started over writing at age of 2years(2year )
• Self dressing at age of 3year (3year)
• Button unbutton copy square cross at age of 4 year

21. Social and adaptive
milestones
• Started giving social and interactive smile at 2.5 months(2
months)
• Hand regard ; recognising mother at 3months(3 months)
• Spoke monosyllables at 7 months(6 months)
• Spoke disyllables at 8.5 months(9 months)
• Could make small sentences 2 years(normal)
• Normal speech ,asking questions at 3 years(normal)
• Could tell story ,recite poem at 4 years(normal)

22. Dietary history
• Child was exclusively breast fed till 6 months of age
• Complementary feeding started after 6 months
Daily calorie requirement for child= 1350 kcal
Daily protein requirement for child= 20.1 g

23. Dietary history cont….
• Calorie deficit= 1350-1132.5
=217.5 kcal
• Total protein intake= 29.15 gram

24. DIETARY PLAN
TIME FOOD ITEM AMOUNT CALORIES IN
KCal
PROTEIN IN
GRAMS
6 30 am Roti
Boiled egg
1
1/4
85
22.5
2.95
3.25
7 am Tea
bread
1 cup
1 slice
75
85
0.9
2.95
8 am Rice
dal
½ katori each 85
100
1.7
2.5
12 30 pm Rice
dal
½ katori each 85
100
1.7
2.5
2 00 pm Mango
sattu
1(medium)
1 tablespoon
160
90
2.0
5.0
3 30 pm rice ½ katori 85 1.7
5 ;30 pm Potato chips
Lays classic
1
five rs pack
160 2
TOTAL 1132.5 29.15

25. Immunization history
Well immunised for age
sughandha age-4 years 8 months, female
BCG
OPV-0
Hepatitis B-0
7/09/2010
DPT-1(6 weeks)
OPV-1
Hepatitis B
23/11/2010
DPT-2(10 weeks)
OPV 2
Hepatitis B-2
20/01/2011
DPT-3(14 weeks)
OPV 3
Hepatitis B-3
1/03/2011
Measles(9 months)
Vit A
19/6/2011
Dpt booster
Measles
Opv booster
12/1/2012

26. FAMILY HISTORY
• No history of any stillbirth, miscarriage or childhood death in
family
• No history of tuberculosis in family
grandfather, grandmother and father suffer from filariasis.

27. PERSONAL HISTORY
• Mixed Diet
• Normal sleep pattern (8-10 hr)
• Normal bladder & bowel habit
• No history of blood transfusion
• No known drug allergy

28. General Appearance(subjective)
• Appears to be acutely ill
• Able to speak a normal-length sentence without stopping to
take a breath
• Character of cry – hoarse
• Activity level - moderate
• Mental status -well oriented to time, place, and person
• Emotional reaction towards parent was positive and towards
examiner was negative
• Hygiene –inadequate

29. GENERAL
EXAMINATION
• Afebrile
• Pulse -130/ min ,regular , Adequate in volume ,synchronous
• Pallor- present
• Icterus- absent
• Cyanosis- absent
• No clubbing
• No pedal edema
• No thyroid enlargement.

30. REPIRATORY SYSTEM
• INSPECTION-
• shape of chest –circular
• Bilaterally symmetrical
• Trachea central in position
• Trail sign absent
• No drooping of shoulders
• No localised bulge/retraction
• Movement- abdominothoracic
• Symmetrical range of movements on both sides
• No suprasternal ,intercostal or subcostal recessions

31. Palpation
• No tenderness
• Tracheal position - midline
• Chest wall not tender
• Crepitus – absent
• Spinal abnormality- absent
• Nodes (axillary, supraclavicular, cervical)- not palpable
• No masses felt
• apical beat- in 4th inter costal space along midclavicular line

32. Percussion
•
comparable notes on all palpable areas on both sides
• Liver dullness started on 7th inercoastal space

33. Auscultation
• Normal vesicular sound heard over chest
• Intensity of breath sounds normal
• Vocal resonance- symmetrical on both sides
• No pleural rub
• No added sound

34. Systemic examination
CIRCULATORY SYSTEM-
• S1 and S2 heard , no added sound , no murmur
ABDOMINAL-
• scaphoid in shape umbilicus was central in position ;everted ,
soft, non tender , no palpable mass ,no palpable organomegaly.

35. Anthropometric assessment
 WEIGHT
• Weight of child=18.3 kg
• Weight for age= (Age in yrs x 2) + 8 kg
= (5 x 2) + 8
=18 kg
 HEIGHT
• Height of child=102cm
• Height for age=(age in years x 6)+77
• = (5 x 6)+77
=107 cm
102/107 x100=95.32%

36. Anthropometric assessment
• Head circumference=49cm
(Normal for age- 48.5-51.5 cm)
• Mid upper arm circumference =17cm
(Normal for age- 17cm)

37. DIAGNOSIS
• A 5yr old girl Sugandha daughter of Guddu Ram and
Prabhawati Devi resident of Wabhanpura is suffering from
cough and fever since 3 days. This is probably a case of URTI.

38. CONCLUSION
 MEDICAL PROBLEMS:
SUGHANDHA
• Cough
• Fever
• filariasis in grandfather , grandmother and father.

39.  LIVING CONDITIONS
• NO bathroom; toilet; kitchen
• Defaecation in open space
• Natural ventilation- inadequate
• Natural lighting- inadequate
• General cleanliness of rooms- inadequate
• Overcrowding –present

40. • source of water supply- hand pump(35feet)
• storage utensils- uncovered
 REFUSE DISPOSAL:-
• Thrown near the house
• Water logging in nearby areas & open drains personal
 PERSONEL HYGEINE
• Nails-unclean
• Hand washing practices: After defecation-ash/mud
• No handwashing Before cooking or taking meal

41.  SOCIAL AND REPRODUCTIVE
• Lack of family planning.
• Alcohol and tobacco addiction of father .
• Domestic violence due to desire for a male child
• lack of awareness about antinatal care

42. CURE AND REMEDIES
Medical
 treatment for the current medical conditions of
sughandha and other family members.
LIVING CONDITIONS
• toilet should be constructed.in house.
• Correction of ventilation and lighting.
• General cleanliness of rooms should be ensured.
• correction of overcrowding.

43. DISEASE
LOW INCOME
DESIRE FOR
MALE CHILD
LOWER
IMMUNITY
IMPROPER
SEWAGE SYSTEM
DIRTY
SURROUNDINGS
OVERCROWDIN
G
STRESS IN
FAMILY
MALNUTRITION
MORE NO Of
CHILDREN
LACK OF
AWARENESS
ALCOHOLISM
POOR CHILD
CARE
LACK OF
TOILET
IMPROPER
HYGEINE
LOW
EDUCATIO
N

44. • source of clean water should be ensured.
• storage utensils should be kept covered.
REFUSE DISPOSAL:-
• Should be disposed off properly.
• Correction of Water logging
PERSONEL HYGEINE
• Proper cutting of nails
• Hand washing practices: should be followed.

45. RECOMMENDED DIETARY
PLAN
TIME FOOD ITEM AMOUNT CALORIES IN
KCal
PROTEIN IN
GRAMS
6 30 am Roti
Boiled egg
1
1/4
85
22.5
2.95
3.25
7 am Tea
bread
1 cup
1 slice
75
85
0.9
2.95
8 am Rice
dal
½ katori each 85
100
1.7
2.5
12 30 pm Rice
dal
½ katori each 85
100
1.7
2.5
2 00 pm Mango
sattu
1
1 tablespoon
160
90
2.0
5.0
3 30 pm rice 2 85 1.7
5 ;30 pm Potato chips
Lays classic
1
five rs pack
160 2
TOTAL 1132.5 29.15
2 slice
6 pm Roti
sabji
1 pc
½ katori
85
85
2.95
1.5
5.9170
1387.5 36.55

46. SOCIAL AND REPRODUCTIVE
• family planning should be ensured,if not proper ANC should
be ensured in subsequent pregnancy.
• De addiction of father .
• Counselling about desire of a male child.

48. • Tea-
2 teaspoon sugar+ 50 ml toned milk
BACK TO MAIN

49. Types of families
• Nuclear-married couple and their children still regarded
as dependents
• joint/extended-
• Three generation family-people of three generations
living together.

50. • Mid arm cicumference- 9-11 at birth, 16 at 1yr then
negligible(0.25cm/yr) so at 5 years it equals
• 16+4*0.25
• =16+1
• = 17 cm
BACK TO MAIN

51. • VENTILATION
• FRESH AIR SUPPLY OF 3,000
C.FT/PERSON/HOUR(DE CHAUMONT)
• ADEQUATE CROSS VENTILATION SHOULD BE
MAINTAINED
• DOOR AREA +WINDOW AREA+VENTILATOR AREA
SHOULD BE ATLEAST 2/5TH OF TOTAL FLOOR AREA.

52. Types of fever
• Continuous-when body temperature never touches
normal and daily fluctuations are less then than 1 degree
celcius
• Remittent-daily fluctuations exceeding 2 degree celcius
• Intermittent-temperature may touch or remain normal
daily(quotidian),every alternate day (tertian) or after
every two days (quartan)

53. • Brassy: laryngitis
• Barking: hysterical
• Bovine: left recurrent laryngeal nerve paralysis
• Whooping: pertussus

54. • Relation to posture
• Occurs in suppurative lung disease.
• lung abscess: on lying on the healthy side
• bronchiectasis: on leaning forwards.
• In bronchitis ,wheezing and congestive heart failure
cough is worse on lying down.

55. Character sputum
• Caseous: TB
• White grey: smoker or irritation
• Yellow/green: infection
• Brownish: amoebic lung abscess (chocolate/ anchovy
sauce)
• Frothy: pulmonary edema
• Thick mucoid: asthma
• Watery: alveolar cell carcinoma
• Saliva: hysterical

56. • Odor Of sputum
• Offensive odor = anaerobic infection

57. • Associated pain
• Pleuretic (pleurisy)
• Retrosternal (trachiitis)
• Muscle pain: from exertion

58. • Timing of cough
• At night: bronchial asthma & Left ventricular failure.
• Early morning cough: smokers.
• Episodic: Asthma

59. overcrowding
• Colds, asthma, influenza and diarrhoea
• Studies in New Zealand (Kearns et al 1992), Jakarta
(Clauson-Kaas et al 1997) and England (Martin
• 1976) gathered data through self-report and concluded
that coughs, colds, asthma, influenza and diarrhoea are
associated with household size and number of children
per household.

60. • Sex separation- owercrowding is considered to exist if 2
persons above 9 years of age not husband and wife,of
opposite sexes are obliged to sleep in the same room.

61. OVERCROWDING
No of rooms persons
1 2
2 3
3 5
4 7
5 or more 10additional 2 for each further room

62. Trail sign
• In a child with marked tracheal displacement ,clavicular
head of the sternomastoid muscle is pushed forward as
a visible swelling on the displaced side.

63. • Marked suprasternal recessions are suggestive of
narrowing or obstruction of upper airways eg acute
laryngotracheobronchitis etc

64. CRY
It is the signal of discomfort ,boredom or hunger.
• High pitched cry-cerebral irritation and raised ICT
• In arthritis, osteomyelitis, abscess ,peritonitis-crying
become worse on picking up
• Hoarse crying is a feature of excessive crying-cretinism
,laryngitis ,laryngotracheobronchitis ,paralysis of left
recurrent laryngeal nerve

65. Hyperemesis gravidarum
• It is a severe type of vomiting of pregnancy which has
got deleterious effect on the health of the mother and/or
incapacities her in day to day activities.

66. roti
• 100 g of atta =350 kcal
• therefore
• 25 g atta = 350/4=85 kcal
• Likewise protien =2.95
kcal
• Total atta used per day by
the family=500 g
• Total numbers of rotis
made per day =20
• Atta /roti=500/20 =25g

67. VENTILATION
• FRESH AIR SUPPLY OF 3,000
C.FT/PERSON/HOUR(DE CHAUMONT)
• ADEQUATE CROSS VENTILATION SHOULD BE
MAINTAINED
• WINDOW AREA SHOULD BE 1/5TH OF FLOOR AREA
• DOOR AREA +WINDOW AREASHOULD BE ATLEAST
2/5TH OF TOTAL FLOOR AREA.

68. OVERCROWDING
Area (in sq. metre) No. of persons
11 or more 2 persons
9 to 10 1.5 persons
7 to 9 1 person
5 to 7 0.5 person
Under 5 Nil
•The WHO accepted standards for floor space are as follows. A baby under 12 months
is not counted, and children between 1 to 10 years are counted as half a unit.

69. ANC
• Generally check up is done at interval of 4 week for 28
weeks at interval of 2 week for 36weeks.
• But according to WHO 4 visit in developing countries can
be sufficient in pregnancy

70. Classification
of malnutrition by IAP
Weight for age Grade of malnutrition
>80% Normal
71-80% Grade 1
61-70% Grade 2
51-60% Grade 3
<50% Grade 4

71. Weight for height Nutritional status
>90% Normal
85-90% Borderline
75-80% Moderate
<75% Severe

72. Head circumference to age
Age Circumference (in cms)
1 month 32-35.5
6month 40-43.5
1year 43.5-46.5
2year 45.5-49.5
3year 46.8-5
4year 47.5-50.5
5year 48.1-51.5

73. Hyperemesis gravidarum
• It is a severe type of vomiting of pregnancy which has
got deleterious effect on the health of the mother and/or
incapacities her in day to day activities.
Low carbohydrate reserve
Hyperemesis gravidarum

74. Grand father
Grand mother
aunt
Father mother,Sughandha and three siblings