GROUP 7

General information:

• Name :Mrs. Kamala

• Age : 69 yrs
• Gender : Female
• Address:3, Agathiyan Street, Pudupet.
• Education :Upto 8th std
• Occupation : Farmer
• Religion : Hindu
• Ration card colour :Yellow
• Nearest Health care facility: PHC lawspet
AREA MAP:
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Lawspet
PHC

PUDPET MAIN ROAD

Demographic Details :
SL.n Name Age Relation to the head Education Occupati Marital Income Chronic
o /Sex on status Illness

1 Kamala 69/F self 8th NO job Married - HTN

2 Krishnaveni 42/F Daughter illeterate DRL Married 12,000 -

3 Sethuraman 38/M Son 12th Driver Widowed 10,000 -

4 Malarkodi 33/F Daughter in law 10th Housewif Married - -

e

5 Kavitha 25/F Grand daughter CA Studiying Married - -

6 Vasanth 21/M Grand son BSc.Micro Working Single 50,000 -

in JIPMER

7 Durai Murugan 7/M grandson - Student Single - -

8 Rhagavan 2/M grandson - - Single - -

 CHIEF COMPLAINTS:

• Known case of hypertension for

past 15 years.
HISTORY OF PRESENTING ILLNESS:
• The patient was normal 15 years back. Then she
developed giddiness which was relieved by taking
rest.
• History of few episodes of headache and fainting
• History of chest pain along right pectoral region for
past 4 days
• No history of nasal bleeding, blood vomiting.
• No blurring of vision, breathlessness, and sweating.
• No history of loss of appetite, loss of weight
• No history of thyroid problems
• No history of polyphagia, polyuria and polydipsia.
• No h/o any neurological syndromes.
Course of Illness:

• She was perfectly normal 15 years back,

then she had developed few episodes of
giddiness, headache and fainting. She
went to GH, there she was diagnosed as
Hypertensive and the recorded value is not
known by the patient.
• She was given Amlodipine 5mg OD in GH
and started to visit Lawspet PHC one in a
month there she has been advised to take
Amlodipine TD 5mg and told to reduce
salth intake and to reduce her body
weight.
• She does not had any similar compliants
of giddiness while following the
medications regularly.
• She have chest pain over right pectoral
region for past 4 days.
• During her last visit to the Lawspet PHC
her blood glucose level was checked and
known to be completely Normal.
PAST HISTORY:

• No H/o DM, TB, Asthma or any

other chronic illness
• No H/o of previous surgery
• No h/o any trauma
 PERSONAL HISTORY:

• Normal appetite, Mixed Diet

• Normal sleep patterns
• Normal bowel and bladder movement
• No Physical activities
• She chews Tobacco
• No h/o of smoking or alcohol consumption.
 Nutritional Status
FOOD ITEMS CALORIES (kcal) PROTEIN (gm)
MORNING 4 idly 300 8
5 spoons 320 15
coconut chutney
tea 75 5
ATERNOON 4 cups rice 440 4
3 cups sambhar 330 14
EVENING tea 75 5
DINNER 4 dosa 500 12
5 spoons tomato 50 1.7
chutney
 RECOMMENDED INTAKE DEFECT\EXCESS
CALORIES (kcal) 2300 2463 163
PROTEIN (gm) 64 62 2
 Salt and oil consumption:

• Salt Consumption – Tata iodised salt

11/2 kg/month = 1500gm/30 days
= 49.8gms/day
= 6.8 gms/day/person
• Salt Consumption – Reined sunflower oil
1 l /month = 10000ml/30 days
= 32.4 ml/day
= 5 ml/day/person
 Socioeconomic History:
• Debits / loan : No debt or loan
• Total Income of the family : 70000 /- per month
• Per Capita income : 8,750- per month per person
• Socioeconomic status as per Modified Kuppuswamy scale
: Upper middle calss
 Family History:

• Type of Family : Three generation family

• Number of family members :8
• No history of any chronic illness in the family
• NO addiction to alcohol or smoking among family
members
• No history of any domestic illness
 Environmental History:

• Type of house : PUCCA

• Number of rooms : 5
• Number of persons per room : 2
• Overcrowding: No overcrowding
• Kitchen: separate
• Fuel used :LPG
• Indore pollution as there is no cross ventilation
• Source of water supply : Municipal Corporation
• Lightning : Adequate
 Cont…
• Latrine : Household Sanitary latrine
• Waste Disposal : Garbage – Dustbin
Sullage – open drainage
Sewage – Septic Tank
• Drainage system : proper, open type
KAP

• She is aware of diet control but not practicing

it.
• She has the practice of missing medicines.
• She is not aware to do daily physical activities
and neither practising it.
General Examination
• The patient was conscious, cooperative, oriented to time,
place, person, well built and nourished
• No pallor
• No icterus
• No Cyanosis
• No clubbing
• No Lymphadenopathy
• No edema
• No thyroid problems
Vital Signs

• Pulse – 80 beats/min.
• Normal rate, normal rhythm, normal volume, normal
character, condition of vessel wall is normal, No thikening
and the peripheral pulses are felt at dorsalis pedis artery
and posterior tibial artery
• Temperature – Afebrile
• Respiratory Rate – 19 breaths/min
• Blood pressure(During measurement) – 140/100 mm Hg
(She missed Amlodipine the previous day befeore
examination)
Anthropometry

• Height – 148 cm
• Weight – 65 kg
• BMI – 29.67  Class I obese (According to Asian
Classification)
• Hip circumference – 94 cm
• Waist circumference – 115 cm
• Waist to hip ratio – 0.81 ( Normal <85)
WHO-ISH Chart risk predictions for CVD

According to WHO –ISH Chart :

The index case is having 10-20% risk
of developing CVD
Systemic Examination

• CVS  S1, S2 heard normally, no murmurs

• RS  Normal vesicular breath sounds heard, no added
. sounds
• P/A  No tenderness, No organomegaly
• CNS  No focal neurological defects, Normal gait,
reflexes are normal and there is no loss of sensation.
Clinical Diagnosis

• Kamala, a 69 year old female(housewife) who is a known

Chronic hypertensive for past 15 years, taking
Amlodipine(5mg) daily twice but missed one before
examination and visting Lawspet PHC once per month.
• On examination her BP was 140/100 mm hg which indicative
for Stage 1 Hypertension
• Modifiable Risk Factors: too much salt intake, obesity,
chewing pan, lack of physical activities
• Non Modifiable risk Factors:Age
• History of pain over the right pectoral region for past 2 days
may be the indicative of progression of HTN to
complications.
Family Diagnosis

• It is a joint family belonging to upper middle class

according to modified kuppuswamy scale.
• She was given good care by her family members.
• No addiction to smoking/alcohol among family
members.
• No disputes among family members or neighbours.