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
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.
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
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
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
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
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
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