This document contains a case summary of a 26-year-old female named Suja. It includes information on her family history, medical history, housing conditions, dietary habits, obstetric history with her most recent delivery, and examinations of her and her 1-month old infant. Her family lives in a owned pucca house with inadequate sanitation and overcrowding. Her mother has diabetes mellitus. Her infant is growing normally and has received the recommended immunizations to date.

1. RESHMA.HC & SHAHNAZ BEEGUM
7th SEMESTER ,MBBS

2.  NAME : SUJA
 AGE : 26yrs
 SEX : female
 HOUSE NO : TC 2058
 WARD NO : 9
GENERAL INFORMATION

3. FAMILY PROFILE

4.  TYPE OF FAMILY : extended
 FAMILY COMPOSITION
FAMILY HISTORY
NAME RELATION
WITH
HEAD
AGE SEX MARITAL
STATUS
(yes/no)
Edn Occn. Inc.
(/month)
Immn. Health
problems
1.Sudhevan
2.Vasantha
3.Suja
4.Manikutan
5.Vaishnav
6.Vaishnavi
…….
wife
Daughter
Son-in-law
Grand son
Grand -
daughter
60
52
26
32
6
1 mnth
M
F
F
M
M
F
Yes
Yes
Yes
Yes
No
No
SSLC
SSLC
+2
SSLC
UKG
……..
Coolie
……..
………
Coolie
............
……….
8000/-
0
0
10000/-
0
0
Unknown
Unknown
Unknown
Unknown
Adequate
adequate
None
Diabetic
None
None
None
None

5.  TOTAL FAMILY INCOME FROM ALL SOURCE : 18000/-
 PER CAPITA INCOME : 18000/6 = 3000
 Economic status – upper middle class

6. MEDICAL HISTORY OF FAMILY
 Suja’s mother is suffering from DM for 10 yrs
 Diabetic foot present
 Patient developed increased thirst, dryness of throat
& numbness of extremities 10 yrs back following
which she underwent blood tests & DM detected
 She is on oral hypoglycemics since then.

7.  Her sugar level is not under control
 Oral tablets changed to insulin
 Treatment is taken from PHC at Pangappara
 No services from nearest subcenter and anganwadi
 suja’s father has undergone TURP 6 months ago at
MEDICAL COLLEGE,TRIVANDRUM
 Due to expiry of his RSBY card,he had to pay cash for
it.

8. A) Housing
 Owned
 Pucca house
 No. of living rooms: 2
 Location: suitable land
ENVIRONMENT

9.  Kitchen,bathroom and sanitary latrin present
 Adequate ventilation
 Adequate natural lighting
 Artificial lighting source : flurescent lamps
 General cleanliness of rooms - inadequate
 over crowding present

10.  kitchen:
 a) windows : adequate
 b) smoke outlet: Absent
 c) Floor : Pucca
 d) kitchen : separate
 e) fuel used : LPG

11.  Source of water supply : well water…using boiled
water….<15ft from latrin…unprotected

12.  Thrown near the house
REFUSE DISPOSAL

13.  Water logging in nearby areas & open drains

14.  Cloths are put on the ground near to waste

15.  Positive container present

16.  Domestic animal : one dog
 Cattle shed: absent

17. REMEDIES
Medical
 Treatment for the current medical conditions
of family members.
LIVING CONDITIONS .
 General cleanliness of rooms should be ensured.
 source of clean water should be ensured.
 storage utensils should be kept covered

18. REFUSE DISPOSAL:-
 Should be disposed off properly.
 Correction of Water logging
PERSONEL HYGEINE
 Proper cutting of nails
 Use properly cleaned cloths only

19. HISTORY OF POSTNATAL
MOTHER

20.  Bathing habits- daily
 Nails-unclean
 brushing teeth- daily (once)
 Hand washing practices: after defecation , before &
after taking meals
PERSONAL HYGIENE

21.  Menarche at 12yrs
 Regular periods
 No h/o dysmenorrhea/menorrhagia
MENSTRUAL HISTORY

22.  AGE OF MARRIAGE :
 Husband – 26yrs
 Wife – 20yrs
 Became pregnant 6 months after marriage
 First delivery at 21yrs
 Spacing by using condoms for 5yrs
 No h/o infertility treatment
MARITAL HISTORY

23.  First pregnancy at 21yrs
 Iron & folic acid taken
 Two doses of TT taken
 No h/o GDM/GHTN
 No h/o of abortions/still birth/MTP
PAST OBSTETRIC HISTORY

24.  LMP : 7/8/15
 EDC : 15 /04/16
 Iron & folic acid taken
 Two doses of TT taken
 5 times she consulted her doctor during pregnancy
for regular check up
 No h/o of antenatal complications
ANTE-NATAL HISTORY

25.  Full term normal vaginal delivery coducted at SRI-
RAMAKRISHNAMISSION HOSPITAL,Sasthamangalam
on 07TH APRIL 2016.
 About 10000/- is spent for pregnancy care
 System of treatment- Medicine.
 Nature of treatmnt - private
INTRA-NATAL HISTORY

26.  Birth weight : 3.5gm
 Baby Cried soon after birth
 Breast feeding started within 1hr
 Breast feeding adequate
 Lactogen is also given
 Immunization card present
 Adequately immunized for age
POST NATAL HISTORY

27.  Aware of family planning
 Condoms used for 4 yrs aftr first delivery
 Family planning advice was given by doctor
 As per his advice tubectomy was done after 2nd
delivery.
H/O FAMILY PLANNING

28. DIETARY HABIT
TIME FOOD ITEM AMOUNT CALORIES IN
KCal
PROTEIN IN
GRAMS
7 am Tea
Biscuits
1 cup
2
70kcal
66.8
2
4.8
8 am Appam
Payaru curry
3
2 table spoon
294
100
5.04
7.2
12 30 pm Rice
Fish fry
Carrot thoran
3 cup
2 pieces
1 table spoon
350
100
7.2
4.8
20
0.135
4 00 pm Tea
Biscuits
1 cup
2
41.5
66.8
1.6
4.8
8 00 pm Rice
Fish fry
Carrot thoran
1 cup
2 pieces
1 table spoon
350
100
7.2
4.8
20
0.135
TOTAL …………….. …………… 1645.7 61.25

29.  Energy requirement = 2500 kcal/day
 Total energy consumed = 1645.7kcal/day
 Calorie deficit of 854kcal/day
 Protein requirement = 1gm * body wt.+19 = 94gm/day
 Total protein consumed = 61.25gm/day
 Inadeuate .

30.  Family advised to increase the food quantity to
coverup the food deficit.
 Advise to take protien and calcium rich food such as
milk and grams.
 Advice to take fruits and leafy vegetables.
 Advice for postnatal exercises
CORRECTION OF DIETARY
CONSUMPTION

31. DIETARY PLAN
TIME FOOD ITEM AMOUNT CALORIES IN KCal PROTEIN IN GRAMS
7 am Tea
Banana
1 cup
2
70
200
2
2
8 am Appam
Payaru curry
3
2 table spoon
294
100
5.04
7.2
10 am Milk
Egg
1cup
1
140
80
6
6
12 30 pm Rice
Fish fry
Ca
Sambar
2cup
2 pieces
1 table spoon
1cup
350
100
7.2
50
4.8
20
0.135
2.5
1;30 pm Mango 1 148 1.2
4 00 pm Tea
Vada
1 cup
3
70
150
2
3
7 00 pm Rice
Fish fry
Drumstick leaves -
thoran
Sambar
Pappadam
2cup
2 pieces
200gm
1 cup
2
175
100
184
50
40
8
20
13.4
2.5
1
10.oopm Milk 1 cup 140 6
TOTAL …………….. …………… 2525.5 125.24

32.  Exclusive breast feeding upto 6 months
 Supplimentary feeding should start at 6 months
 Adequately immunise for age
ADVICE FOR BABY CARE

33. EXAMINATION OF MOTHER

34.  Coperative,consious and well oriented to surroundings
 Ht – 160cm wt – 75kg
 Moderately bulit and nourished
 Pallor- absent
 Icterus- absent
 Cyanosis- absent
 No clubbing
 No pedal edema
 No thyroid enlargement/neck swellings
GENERAL EXAMINATION

35.  Afebrile
 Pulse -80/ min ,regular , Adequate in volume
 BP not recorded
 Repiratory rate – 17/min , regular

36.  CVS – s1,s2 heard, no murmurs
 Resp – air entry bilaterally equal,no
rhonchi/crepitation
 CNS – HMF/SNS/MNS/CN appears to be normal
 GIT – No abdominal tenderness/distension
SYSTEMIC EXAMINATION

37. EXAMINATION OF INFANT

38.  Active and playful
 Moderately bulit and nourished
 Pallor- absent
 Icterus- absent
 Cyanosis- absent
 No clubbing
 No pedal edema
 No thyroid enlargement/neck swellings
GENERAL EXAMINATION

39.  CVS – s1,s2 heard, no murmurs
 Resp – air entry bilaterally equal,no
rhonchi/crepitation
 CNS – appears to be normal
 GIT – No abdominal tenderness/distension
SYSTEMIC EXAMINATION

40. ANTHROPOMETRIC ASSESSMENT
WEIGHT
 Weight of child=5.5kg
 Weight for age= (Age in months+9)/ 2
= (1+9)/2
=5kg
HEIGHT
 Height of child= 55 cm

41.  Head circumference = 36cm
(Normal for age- 35-38cm)
 Chest circumference = 33cm

42.  Mile Stones of development (for that specific age):
Achieved
 Personal Hygiene: adequate
 No cases of diarrhoea/pneumonia

43. VACCINES DATE
BCG
OPV-0
Hepatitis B-0
07/04/16
DPT-1(6 weeks)
OPV-1
Hepatitis B
21/05/16
IMMUNISATION HISTORY