1. The document describes a psychosocial case of a 37-year-old woman who presented with pain in her abdomen for 1 month and weakness. She has a history of sterilization failure 2 years ago and now has 4 living children. 2. On examination, she was found to be moderately built and poorly nourished with pallor. Investigations revealed cholelithiasis and moderate anemia. Her 11-month-old daughter was also found to be underweight. 3. She was diagnosed with cholelithiasis, moderate anemia, and amenorrhea for 2 months with significant nutritional deficits of 74% calories and 52% protein intake. Her living conditions and family

1. CLINICO
PSYCHOSOCIAL CASE
5/8/2021 1
Moderated by:
Dr Tarundeep Singh
Associate Professor
Department of Community
Medicine and School of Public
Health, PGIMER
Presented by:
Dr Shruthi Rajan
Junior resident
Department of Community
Medicine and School of
Public Health
PGIMER

2. LOCATION
• #2**, Small flats, Housing board colony,
• Sector 49-C, Chandigarh
• Hindu , Nuclear family
• Originally from Sitamarhi District, Bihar
• Living in Chandigarh for the past 20 years
5/8/2021 2

3. FAMILY PROFILE
5/8/2021 3
NAME AGE RELATION EDUCATIO
N
OCCUPATION INCOME HEALTH STATUS
Mr. P** 40 yrs. Husband
(HOF)
7th Std Vendor Rs.8000
/month
Apparently
Healthy
Mrs. R** 37 yrs. Wife 5th Std Homemaker Nil Index Case
A*** 11 yrs. Son 5th Std Gov Model Primary
School- 49-D
Nil Apparently
Healthy
B*** 8 yrs. Son 3rd Std Gov Model Primary
School- 49-D
Nil Apparently
Healthy
C*** 7 yrs. Son 1st Std Gov Model Primary
School- 49-D
Nil Apparently
Healthy
D*** 11
mnths
Daughter _ _ Nil Apparently
Healthy

4. FAMILY TREE
5/8/2021 4
40 years 37 years
8 years 7 years
11 years 11 months

5. SOCIO-ECONOMIC STATUS
• According to Modified Kuppuswamy Classification 2019, SES:
Upper Lower Class with score of 8
• Nearest Health Facility: CD-49
• Nearest Secondary Health Facility: CH-45
• Nearest Tertiary Health Facility: GMCH-32, Chandigarh
5/8/2021 5

6. HOUSING &
ENVIRONMENTAL
CONDITION
• Rented pucca house
• Roof concrete, floor cemented
• 1 room – 2 beds
• 1 kitchen and 1 bathroom attached
• Rent = Rs. 975/month
5/8/2021 6

7. • No windows, one
main door
• Natural light –
inadequate
• Artificial light –
adequate
• Ventilation –
adequate, no cross
ventilation
5/8/2021 7

8. • Overcrowding present
• LPG is used for cooking
• House Flies present
• Drinking water – Municipal
water ( no filtration method
used)
5/8/2021 8

9. KITCHEN BATHROOM
• Garbage disposal –
daily
• Sanitary latrine
(Indian type) with
running tap water
5/8/2021 9

10. CHIEF COMPLAINTS
• Pain abdomen 1 month
• Weakness since 1 month
5/8/2021 10

11. HISTORY OF PRESENTING
ILLNESS
• Patient was apparently healthy 1 month ago when she developed
pain abdomen, acute onset, colicky in nature, right sided not
associated with fever, vomiting or loose stools
• Taken to CH-45 by husband. Admitted for 2 days. Treated and
advised USG.
5/8/2021 11

12. • 3 days later, she developed another episode of pain abdomen,
acute onset, colicky in nature, severe in intensity (she thought she
was going to die)
• Taken to GMCH-32 by husband with the help of neighbour
• Admitted on 16/1/20 , for 3 days
• USG done = Cholelithiasis
5/8/2021 12

13. • C/o weakness since the last pain episode, associated with
breathlessness and palpitations on exertion, worsened in the last
2 weeks
• NYHA classification 3- Marked limitation in activity due to
symptoms, even during less than ordinary activity (Eg: house
hold chores). Comfortable only at rest
5/8/2021 13

14. H/o loss of appetite
No h/o chest pain, sweating
No h/o cough, cold or fever
No h/o vomiting, loose stools or blood in stools
No h/o swelling of feet or face
No h/o blood loss
5/8/2021 14

15. MENSTRUAL HISTORY
• Attained menarche at 12 years
• 3-4 / 28-30, regular cycles until last year
• No pain, no clots (2-3 pads/day)
• LMP= 2/12/19
• Currently no use of contraceptives
• UPT done (in CH-45)= Negative (9/1/20)
5/8/2021 15

16. MARITAL HISTORY
• Married for 20 years
• Home town- Sitamarhi district,
Bihar
• Non consanguineous marriage
• Moved to Chandigarh
after the wedding
5/8/2021 16

17. PAST OBSTETRIC HISTORY
• Obstetric score = Para 4 Living 4 Abortion 0
• No contraception use between pregnancies
5/8/2021 17

18. 5/8/2021 18
Spontaneous
conception
Unwanted
Booked
pregnancy
ANC period
uneventful
Institutional
delivery
(GMSH-16)
FTNVD
7/M, Immunised
till date
G3 (2013)
Spontaneous
conception
Booked
pregnancy
ANC period
uneventful
Institutional
delivery
(GMSH-16)
FTNVD
8/M,
Incomplete
immunisation
G2 (2012)
Spontaneous
conception
Booked
pregnancy
ANC period
uneventful
Institutional
delivery
(Bihar)
FTNVD
11/M,
Immunised
G1 (2009)
Mother-in-law
insisted on
having third
(girl) child

19. • 3 years later
• Underwent interval tubectomy (female permanent sterilisation
procedure) after motivation by Anganwadi Worker and MultiPurpose
Health Worker (CD - 47)
5/8/2021 19

20. 5/8/2021 20
• Plain Laparoscopic
Tubal Ligation
• GMSH-16
• Sterilisation
certificate received
3/8/2016
• Missed period
• LMP= 6/3/18
• UPT = Negative
(home)
2 years later
• CD- 49 (2-3
days later)
• UPT=
Negative
• Ruled out
pregnancy
i/v/o
anaemia

21. GMSH-16 (30/06/18)- Failed to receive check
up as ANM felt her plea was redundant
GMSH-16 (20/7/18)- UPT + ; Urgent USG for
foetal viability
Private clinic (USG done- 21/7/18) USG=
SLIUG of 9 weeks 4 days (?)
USG LMP=6/4/18; No signature
GMSH-16 (25/7/18)- 19 weeks 2 days
Was told that the pregnancy cannot be
terminated
5/8/2021 21

22. 5/8/2021 22

23. 2nd & 3rd
Trimester
• CD-49 and GMSH-
16 for ANC visits
• TT 2 doses taken
• IFA and Ca taken
Term
38 +4 weeks
• Bleeding PV on 09/02/19 at 4 PM
• Husband took her to GMSH-16
via Ambulance called by ANM (5
PM)
10/02/19
• FTNVD at 9 AM
• 2.6 kg, female child
• Post partum CuT
inserted in GMSH-16
5/8/2021 23
SR, JR – CD 49
informed that
compensation can
be received

24. • Filed for
compensation
• Family
Planning
Counsellor
• GMSH-16
Within 1
month
• Removed
CuT due to
pain and
bleeding
2 months
later
• District Co-
Ordinator of
ICDS
• Anganwadi
• Filed case against
Chandigarh
Administration &
Health
Department
Request for
Legal Aid
5/8/2021 24

25. PAST HISTORY
• No h/o T2DM, HTN, epilepsy, TB or other chronic illness
5/8/2021 25
• No h/o Type 2 DM, HTN, TB in the family
FAMILY HISTORY

26. PERSONAL HISTORY
• Vegetarian diet
• Appetite- reduced
• Sleep- Reduced
• Bowel & Bladder- Normal and regular
• No habit forming behaviour
• No indoor smoke
5/8/2021 26

27. DIET HISTORY
By 24 hr recall method,
5/8/2021 27
Calorie
(Kcal)
Protein
(Gm/day)
Requirement 2230 55
Intake 575 26
Deficit 1655 29
74% 52%

28. PSYCHOSOCIAL HISTORY
5/8/2021 28

29. CONTRACEPTIVE FAILURE
• Did you ever think the operation would fail?
 NO
• Was consent for surgery taken?
YES
• Were you informed about failure rates/ side effects of surgery?
 NO
5/8/2021 29

30. CONTRACEPTIVE FAILURE
• Why do you think your operation failed?
• How did you file for compensation?
• How will you take care of your last child ?
• How does your husband help take care of you and children ?
5/8/2021 30

31. CONTRACEPTIVE FAILURE
• How will you prevent yourself from getting pregnant again?
• Do you think it will fail again?
5/8/2021 31

32. HEALTH BELIEF MODEL
Perceived
susceptibility
Reproductive age
group
Perceived
severity
More
children=
more health
and financial
burden
Perceived threat
She might get
pregnant again as
no contraception in
practice
Cues to action
Mother’s support
Benefits/barriers
• One time
permanent method
• Method may fail
again
Desired behaviour
Use of contraceptives
Self efficacy
She has confidence
that she can do it
again

33. SOCIO ECOLOGICAL MODEL

34. Good health
seeking
behaviour, no
sex preference
Compensati
on received,
Legal aid
Support from
mother,
ANM, AWW
Faith in God
Family
complete
Desperate to
overcome
misery
5/8/2021 34
Why she still has
faith in
health system?

35. Benefits Barriers
5/8/2021 35
Susceptibility Severity
Present condition

36. INVESTIGATIONS
5/8/2021 36
DATE TEST RESULT
13/1/20 USG Abdomen
(private)
Gall Bladder = Multiple echogenic foci
with distal acoustic shadow seen in
lumen largest measuring 21.3mm
Cholelithiasis without cholecystitis
16/1/20 Complete blood count Hb= 8.6 g/L, PCV=26, RBC= 1.89m/L
MCV= 135, MCH= 46, MCHC= 34,
RDW=21, Reticulocytes= ---,
Platelet count= 1.38, TLC= 8.2
DLC= N56/L40/M02/E02/B00

37. DATE TEST RESULT
16/1/20 Serum Electrolytes Na=134 mEq/l, K=3.5 mEq/l,
Cl=106 mEq/l
16/1/20 Renal function test Urea=12 mg/dl
Creatinine=0.5 mg/dl
16/1/20 Liver function test T. Bilirubin = 0.2 mg/dl
ALP= 88 IU/L, SGOT=110, SGPT=64
Total Protein = 7.1 gm/dl, Albumin= 3.5
16/1/20 C-Reactive Protein 2.8 mg/l
16/1/20 PT INR PT=16, PTI= 88, INR=1.15
aPTT=326
5/8/2021 37

38. DATE TEST RESULT
16/1/20 USG Abdomen Gall bladder partially distended. Few
calculi seen, largest measuring 9mm in
the lumen.
Cholelithiasis
Grade 1 fatty liver
16/1/20 Pancreatic enzymes S. Amylase=19 IU/L
S. Lipase= 26 IU/L
5/8/2021 38

39. • Chest X ray PA View
• 16/01/20
• Multiple air fluid levels
5/8/2021 39

40. GENERAL PHYSICAL
EXAMINATION
She is moderately built and poorly nourished,
well oriented to time, space and person.
5/8/2021 40
Vitals
• Respiratory rate=16/min, thoraco-abdominal
• Pulse rate= 96/min, regular
• BP= 100/60 mmHg
• Temperature= Afebrile

41. ANTHROPOMETRY
• Height= 142 cm
• Weight= 33.5 kg
• BMI= 16.6
5/8/2021 41

42. HEAD TO TOE
EXAMINATION
• Pallor + +
• Icterus, cyanosis, clubbing,
lymphadenopathy, oedema not present
• Thyroid, Breast, Spine = Normal
5/8/2021 42

43. SYSTEMIC EXAMINATION
• Respiratory System
 B/L Normal vesicular
breath sounds heard
 No added breath
sounds
• Cardiovascular System
 S1 , S2 heard
 No murmurs
• Central Nervous System
 No abnormality
detected
5/8/2021 43

44. Inspection
• Bilaterally
symmetrical
• All quadrants
move equally
with
respiration
• Laparotomy
scar seen
• No
sinuses/fistulae
seen
Palpation
• Soft, non
tender
• No
organomegaly
Percussion
• Resonant
Auscultation
• Bowel sounds
heard
• Per Abdomen
5/8/2021 44

45. EXAMINATION OF CHILD
An infant who is poorly built and nourished, playful.
There is no pallor, icterus, clubbing, cyanosis,
lymphadenopathy or edema.
Vitals :
Pulse rate : 100/min, regular.
Respiratory rate : 14/min, thoraco-abdominal type.
Temperature : afebrile.
5/8/2021 45

46. ANTHROPOMETRY
5/8/2021 46
Measurement
WHO growth
chart
Category Diagnosis
Weight = 6.1 kg Weight for age
Weight for height
Between -2 to -3 SD
Between -1 to -2 SD
Underweight
Height = 68 cm
Height for age Between -1 to -2 SD Normal
BMI = 13.2
BMI for age Between -1 to -2 SD Normal
Head circumference= 45 cm 15th - 50th centile Between -1 to -2 SD Normal
Mid arm circumference= 12
cm
Shakir tape Moderate Borderline

47. DEVELOPMENTAL HISTORY
5/8/2021 47
GROSS MOTOR FINE MOTOR SPEECH &
LANGUAGE
SOCIAL
Head holding- 4
months
Reaches & grasps
objects- 4 months
Coos – 2 months Social smile – 2 months
Roll over – 6
months
Bi dextrous grasp- 6
months
“Mama,dada”–
9months
Raises arm to be picked
by parents- 6 months
Sit alone – 9
months
Pincer grasp – 12
months
2 words – 18 months Stranger anxiety- 12
months
Crawl – 12 months Scribble – 2 years 2 words(meaning)–
2yrs
“Bye bye”– 18 months
Stand alone- 15
months
Feeds self by spoon –
2 years
Small sentences- 2.5
years
Parallel play- 24 months
Walk alone-18
months
Climbs upstairs – 2
years

48. DIAGNOSIS
A 37 year old female, para 4 living 4, belonging to Upper Lower SES
with history of sterilisation failure now presenting with cholelithiasis
and moderate anaemia with amenorrhea for 2 months with
nutritional deficit of 74% Kcals and 52% Protein with the last born
being underweight
5/8/2021 48

49. GAPS IDENTIFIED
• Health system access
• At 19 +2 weeks, why was abortion not done ?
• Missed immunising 2nd child
• Sterilisation failure compensation received
• Received legal aid from authority
5/8/2021 49
STENGTHS

50. MANAGEMENT
5/8/2021 50

51. INDIVIDUAL LEVEL
a.Cholelithiasis
• Elective
cholecystectomy
• T. Pantoprazole
40mg OD
• T Hyoscine 10
mg SOS
• T. Domperidone
20 mg SOS
• Low fat diet
Anaemia
• Intravenous
Ferrous Sucrose
injections 200 mg
in 200 ml NS
biweekly
• T Ferrous
Sulphate 100mg
BD
• Iron rich diet
(green leafy
vegetables,
a.Calorie
deficiency
• Nutritious diet
• Increase no of
meals
• Fibre rich diet
5/8/2021 51

52. Contraception
• Basket choice
approach
• (repeat Tubal
ligation or
Salpingectomy
or contraception
of her choice)
Mental Health
• Mental and
Emotional
Support
• Counselling
• Visit place of
worship
Amenorrhoea
• Treat anaemia
• Reassurance
5/8/2021 52

53. FAMILY LEVEL
• LAST CHILD – requirement = 150 kcals/kg/day and 3 g/kg/day of
protein
• 6-7 feeds/day
• Increase volume of feeds (include milk and ghee in the diet)
• Multivitamin and minerals – folic acid (1mg/d), zinc (2mg/kg/day)
and Cu ( 0.2-0.3 mg/kg/day)
• Periodic deworming- Tab albendazole 200mg stat, Repeat after 14
days
5/8/2021 53

54. • Vitamin A drops- 2 lakh IU every 6 months
• Sensory stimulation
• Regular weight monitoring of child
• Anganwadi registration of last child
• Family support for hospital admission and treatment
• Immunisation (Td) of 2nd Child
• HUSBAND - counselling for better management/care of family
• Family planning counselling
5/8/2021 54

55. COMMUNITY LEVEL
• Family Planning Indemnity Scheme
 Under Section 1C – Compensation of Rs. 30,000/- received
• MTP Act
• RMNCH+A
5/8/2021 55

56. • ICDS
 Supplementary nutrition ( 300 kcals/day , 8-10 g of protein/day )
 Immunisation
 Health check ups
 Non formal pre-school education
 Referral services
• Beti Bachao Beti Padao Scheme
• RBSK
5/8/2021 56

57. THANK YOU
5/8/2021 57