Clinico social case Presentation of a pregnant lady from Yangon admitted to Central Women Hospital, Yangon, who is living with HIV.

1. CLINICO-SOCIAL CASE
PRESENTATION
University of Medicine (1),Yangon
PSM Posting Group 5, Sub-groupA
Roll No. 1 – 30

2. FORTHIS CLINICO-SOCIAL CASE,
 Case taking: Done by the whole sub-group
 Presenter: Kyaw San Lin (RN - 21)
 Computer: KayYu San (RN- 4)
KKThwe Sunn (RN - 1)
Kyaw San Lin (RN - 21)
 Pamphlet: KKThwe Sunn (RN - 1)

3. CONTENTS
 Personal Characteristics
 Summary of Relevant Social & Community Aspect
 Summary of Clinical Aspects
 Analysis of the Problem
 Management
 Summary of the Case

4. PERSONAL CHARACTERISTICS
 Age 29
 Sex Female
 Race and Religion Myanmar, Buddhist
 Education 4th Standard
 Marital status Married
 Number of children 2
 Occupation Selling rice & pickled tea (La-phat) at
Thein Phyu Night Bazaar

5. PERSONAL CHARACTERISTICS
 Date ofAdmission 24th August, 2014
 HospitalWard Unit 3, B Block, Central Woman Hospital
 Father
 Name U Sein Win
 Occupation ManualWorker
 Education Read &Write
 Mother
 Name Daw Shwe Mi
 Occupation ManualWorker
 Education Read & Write

6. SUMMARY OF RELEVANT SOCIAL
& COMMUNITY ASPECT
 Personal History
 Occupational History
 Family History
 Attitude towards her illness
 Social Environmental History

7. PERSONAL HISTORY
 Well conscious and can respond to questions
 Hobby - WatchingTV, mainly movies
 Doesn’t have any ambition

8. HER LIFE EVENTS
Childhood life
at Zwe Htaw
village
Moved to
Yangon
Life after
Marriage

9. CHILDHOOD LIFE AT ZWE HTAW
VILLAGE
• Parents - poverty
• Many siblings
Born from a poor
family
• Only Elementary
school present
• Both parents can
only read and write
Primary education
at the village • Far from town
• An hour drive by
motorcycle to
nearest town Thone
khwa
For higher levels of
education…

10. LIFE EVENT AFTER MOVINGTO
YANGON CITY
Moving to
Yangon to her
elder brother at
the age of 19
Assist
household
works for her
brother’s
family
No further
Education and
health
knowledge
gained
Met her
husband-to-be
while hiring
Trishaw

11. MARRIAGE LIFE
Age of marriage – 21 yrs
After 3 yr (age of 24) – 1st child
After another 2 yr (age of 26) – 2nd child
Now, after another 3 yr (age of 29) - 3rd child pregnant
and income becomes insufficient
Lead her to sell goods at the night bazzare

12. OCCUPATIONAL HISTORY
Working hours
From 10 pm to 4 am
Abnormal sleeping
pattern
Hours of sleep per day
4 hours
Insufficient hours of
sleep
• Selling rice & pickled tea (La-phat) at Thein Phyu
Night Bazaar

13. FAMILY HISTORY
• 4 members
• Nuclear type
Her husbandPatient
2nd child1st child

14. HER HUSBAND
 Age – 33 years
 Education – 4th Standard
 Occupation – trishaw driver
 Daily income – 5000 kyats

15. HER CHILDREN
 First child - 5 years old, lives with her grandparents
at Zwe Htaw village since 2012.
 Second child – 3 ½ years old, sent to her
grandparents since she have the present
pregnancy

16. ATTITUDETOWARDS HER ILLNESS
 According to her…
 She has never worked as sex worker
 No pre-marital sexual activity
 No extra-marital sexual activity
 Never transfused blood before
 So,…
 Realised that she got this disease from her beloved
husband.
 Already known the chances of exposure to
premarital and extramarital sexual exposure during
his working period and environment.

17. ATTITUDETOWARDS HER ILLNESS
 But,…
 She understands her husband’s situation
 Still loves him…
 Wants to take medication regularly together with
her husband.
 To get be able to live with her family happily as
normal people.

18. HER CURRENT ENVIRONMENT
 Lives only with her husband in a 10 square feet room
 Shared with other families.
 Share bathrooms and toilets.
 Transportation - easy from her house.
 Bazaar - near her house and she can go easily.
 Water supply - from the Gyo Phyu water pipeline.
 Latrine - sanitary with septic tank attached.
 Refuse disposal - in a nearby public bin.
 Clinics and hospitals - situated near her house

19. SUMMARY OF CLINICAL ASPECT
 History
 Physical Examination
 Investigations
 Provisional Diagnosis

20. HISTORY
 Admitted to the CentralWomen Hospital (CWH)
 On 24th August, 2014
 For acute gastritis and PMCT programme

21. MENSTRUAL HISTORY
 Age of menarche - 13 years.
 28-week cycle, lasts for 3 days, regular, moderate
amount, no dysmenorrhoea.
 LMP - 3rd January, 2014 (not sure)
 MBD - 33 wks 6 days
 EDD - 10th October, 2014

22. PAST OBSTETRIC HISTORY
 The age of marriage - 21 years.
 Single marriage.
 G 3, P 2+0.
 Her 1st child - 5 years old, born at term by urgent
LSCS d/t APH d/t placenta praevia. No 3rd stage &
puerperal complications.
 Her 2nd child - 3 ½ years old, born at term by
elective LSCS d/t previous LSCS. No 3rd stage &
puerperal complications.

23. HISTORY OF PRESENT PREGNANCY
 Unplanned but wanted pregnancy.
 Dx of pregnancy by UCG on March.
 Signs and symptoms of pregnancy such as
morning sickness, and amenorrhoea are also
present.
 Took AN care at 6th month of pregnancy at CWH.

24. HISTORY OF PRESENT ILLNESS
 acute onset
 dull aching pain
 in epigastrium
 1 day duration
 aggravated by taking food
 relieved by taking antacid
 not severe
 No radiation

25. PAST MEDICAL & SURGICAL HISTORY
 No past history of H/T, DM, IHD, epilepsy,TB,
renal diseases or other diseases.
 No history of hospitalization.
 No past surgical history.

26. PAST GYNAECOLOGICAL HISTORY
 No past gynaecological diseases, operations or
treatment.
 Screening of cervical smear has not been done
before.

27. FAMILY, DRUG & PERSONAL HISTORY
 No family history of H/T, DM, PE, or twin
pregnancy.
 No other genetic diseases present.
 No regular taking of drug.
 No known drug allergy.
 No smoking, alcohol drinking, betel chewing or
drugs addiction.

28. CLINICAL EXAMINATION
 General
 CNS
 CVS
 Respiration
 Lymphatics
 Breast
 Abdomen

29. GENERAL EXAMINATION
 Well alert, well orientated, lying comfortably in
the bed, no fever, slightly thin.
 Eyes: Pallor present. No Jaundice.
 Mouth:Teeth and gum are healthy. No tonsillar
enlargement.
 Neck: No visible swelling in the neck.
 Extremities
 Upper limbs: NAD
 Lower limbs: No clubbing, no peripheral cyanosis,
bilateral pitting petal oedema present.

30. CNS EXAMINATION
 Well alert, well orientated.
 Normal cranial nerves, sensory, motor and
peripheral nerves functioning.

31. CVS EXAMINATION
 BP- 110/70 mmHg
 PR – 70 beats/min
 Apex beat - located at the left 5th ICS within the
mid-clavicular line
 Normal 1st and 2nd heart sound
 No added sound

32. RESPIRATORY SYSTEM
EXAMINATION
 Normal vesicular breath sound
 No added sound
 RR – 16/min

33. LYMPHORETICULAR SYSTEM
 No lymph node enlargement.
 No liver enlargement.
 No splenic enlargement.

34. BREAST EXAMINATION
 Well developed.
 Nipple is protruded.
 On palpation of the four quadrants, no abnormal
lump is palpated.

35. ABDOMINAL EXAMINATION
(SUMMARY)
 Fundal Height - 38week size
 SFH- 35 cm
 Single foetus
 Longitudinal lie
 Head presentation
 Not engaged.
 FHS is 160 beats/min, strong and regular.

36. INVESTIGATIONS
 Blood for CP – RBC,WBC, & platelet are normal in
both count and morphology
 Chemical Pathology – Alkaline Phosphatase↑
 Infection screening
 HBs Ag - negative, HCV Ab - negative, Blood for
VDRL – non-reactive
 HIV screening test – reactive, 1st confirmation test –
reactive, 2nd confirmation test – Positive
 HIV screening test of the husband - reactive, 1st
confirmation test – reactive, 2nd confirmation test –
Positive
 CD4 count - 284 cells/𝜇L (Normal - >400 cells/𝜇L)

37. INVESTIGATIONS
USG
 Date of present report 2nd July, 2014
 No. of foetus: Single
 Presentation: Head
 Lie: Longitudinal
 Placental Localization: Anterior, upper
 Amniotic fluid volume: Normal
 Radiologist Comments Single viable foetus
27 week at EGA

38. PROVISIONAL DIAGNOSIS
 29 years old
 G 3, P 2+0
 at 34+6 weeks of pregnancy
 with HIV infection and acute gastritis

39. ANALYSIS OFTHE PROBLEM
 From 3 Aspects:
1. Social Etiology
2. Diagnoses – Clinical & Social
3. Social Implications

40. SOCIAL ETIOLOGY
Social
Etiology
Predisposing
Factors
Enabling
Factors
Precipitating
Factors
Reinforcing
Factors

41. PREDISPOSING FACTORS
 Poverty
 Husband’s daily income - 5 thousand kyats
 Low Education Level
 passed only the 4th Standard
 Poor Health Knowledge
 not interested in seeking health knowledge
 Weak Guardianship
 d/t the large size of her family
 needs personality formation and moral teachings

42. ENABLING FACTORS
 Low education Level of Husband
 Occupation of Husband
 Morality of Husband, Premarital Sexual Exposure,
 Unsafe Sex
 Lack of Premarital Counselling

43. PRECIPITATING FACTORS
 Pregnancy
 increases HIV infection progression, progression to
AIDS and the chance of death.
 Nature of her Occupation
 weakens her health and worsens her condition.

44. REINFORCING FACTORS
 Poor Nutrition
 does not eat any meat other than small fish.
 commonly eats vegetables → low protein diet.
 Lack of Family Support
 Currently, only her husband staying with her
 insufficient as family support.

45. CLINICAL DIAGNOSIS
 29 years old,
 G 3, P 2+0,
 at 33+6 weeks of pregnancy
 with HIV infection and acute gastritis

46. SOCIAL DIAGNOSIS
 Poverty
 Poor education
 Lack of health knowledge especially reproductive
health

47. SOCIAL IMPLICATIONS
Social
Implications
Individual
Level
Family
Level
Community
Level
National
Level

48. INDIVIDUAL LEVEL
 Psychological Stress
 others might ignore her
 socially isolated
 loss of support from family & friends
 emotional breakdown
 fear of opportunistic infections, anticipatory grief,
shame, helplessness, and discrimination

49. FAMILY LEVEL
 Increased risk of transmission of HIV
 from mother to child during pregnancy, birth or lactation
 Financial problems
 Inability to work during pregnancy
 Increase in expenditure of healthcare and health facilities
 Family Burden
 care given to her during gestation period → take effort
and time of family members.
 Reduction of care for other children

50. COMMUNITY LEVEL
Increased risk of transmission
Increased workload for doctors and medico-
social workers

51. NATIONAL LEVEL
 Decreasing Human resources
 Increased incidence and prevalence of HIV
infected person
 Increased workload of health sector

52. Predisposing factors
 Poverty
 Low Education Level
 Poor Health Knowledge
 Weak Guardianship
Enabling Factors
 Low education Level of
Husband
 Occupation of Husband
 Morality of Husband
 Premarital Sexual
Exposure,
 Unsafe Sex
 Lack of Premarital
Counselling
Precipitating factor
 Pregnancy
 Nature of Occupation
Reinforcing factors
 Poor Nutrition
 Lack of Family Support
Clinical diagnosis
29 years old, G 3, P 2+0,
at 33+6 weeks of
pregnancy with HIV
infection & acute
gastritis
Social diagnosis
 Poverty
 Poor education
 Lack of health
knowledge
especially in
reproductive health
Individual Level
 Psychological stress
Community Level
 Increased risk of
transmission
 Increased workload for
doctors and medico-social
workers
Family Level
• Increased risk of
transmission of HIV
• Financial problems
• Family Burden
• Reduction of care for other
children
National Level
 Decreasing Human
resources
 Increased incidence and
prevalence of HIV infected
person
 Increased workload of
health sector
Social Etiology
Social Implication

53. CLINICO-SOCIAL MANAGEMENTS
Mangements
Immediate
Management
Individual
Level
Family Level
Long-term
Management
Individual
Level
Family Level
Community
Level
National
Level

54. IMMEDIATE MANAGEMENTS
 Individual Level
Psychological support and counselling
PMCT
Nutrition
Treatment for acute gastritis
 Family Level
Counselling
Sterilization
ARV Prophylaxis to Baby

55. LONG-TERM MANAGEMENTS
 Individual Level
Social support and ART treatment
Rest
Safe water and Food
Avoid handling pets
Safe Sex
 Family Level
Health Education
Prevention of HIV transmission

56. COMMUNITY LEVEL
 HE about blood transfusion, drug abuse, sexual
promiscuity and their disease
 HE to sex workers about safe sex
 Encouraging the community to help patients by
giving psychological support
 Cooperation and collaboration with social
welfare services such as NGOs

57. NATIONAL LEVEL
 Promoting literacy
 Creating job opportunities
 Promoting national health care services and facilities
 National HIV/ AIDS Control Program (NAP)
 Implementing PMCT programme
 Surveillance against STD in community
 Identify missing cases
 Cooperation and collaboration with INGOs, local NGOs
and services
 Supervision, monitoring and evaluation

58. SUMMARY OFTHE CASE
 A female patient, aged 29, G 3, P 2+0, came to CWH for
acute gastritis and AN Care.
 HIV testing done as part of the AN Care package - positive
result
 Admitted to CWH, B Block, Unit 3 on 24th August, 2014 for
PMCT.
 Her husband tested for HIV - positive.
 Both - low income, poor educational status and lack of
reproductive health education.

59. SUMMARY OFTHE CASE
 CD4 count - <350 cells/mm
 ART treatment
 Her husband - referred toTharketa STI Hospital for ART
treatment.
 Counselling - HIV, PMCT, delivery and infant feeding