CLINICOSOCIAL CASE PRESENTATION-I (RURAL)
Presented by: Dr. Shalini Pattanayak
Post Graduate Trainee, Dept. of Community Medicine,
IPGME&R and SSKM Hospital, Kolkata
PATIENT PARTICULARS:
Name: Mr. Goutam Mondal
Age (in completed years): 49
Gender: Male
Residence: Mondalpara, Muchisa, Budge-Budge-II Block (S-24 Parganas)
State of origin: West Bengal
Duration of stay: Since birth
Religion: Hinduism
Caste: Scheduled Caste (SC)
Marital status: Married
Mother tongue: Bengali
Type of family: Nuclear
Highest level of education attained: Primary school
Occupation: Driver
Relation with Head of the Family (HoF): Himself
Contact number: 933xxxxx24
Total family income per month (in Rs.): 10000/-
Total number of family members: 5
Hence, per capita family income (in Rs.): 2000/-
Therefore, according to the Modified B.G. Prasad Scale (updated in Oct. 2022), his family
belongs to Lower Middle (Class IV) socioeconomic status
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Social security schemes: Swasthya Saathi card, Ration card
Fig. 1. Family Tree of the patient under study
CHIEF COMPLAINTS:
1. Pain in B/L shoulder joints since 1 week
2. Occasional difficulty in breathing, mainly during strenuous activities since last 1.5 years,
aggravated since last 10 months
HISTORY OF PRESENT ILLNESS:
1. The patient was apparently well 1 week back, after which he developed pain in B/L shoulder
joints. It was gradual in onset, more in the left shoulder joint than in the right, localized, and
aggravated mainly after carrying heavy objects. There was no significant H/O trauma
2. The patient also complained of occasional exertional dyspnea, mainly during climbing stairs,
cycling or walking for a long duration, since 1.5 years, which was aggravated since the past
10 months
HISTORY OF PAST ILLNESS:
1. The patient had experienced sudden onset excruciating chest pain with profuse sweating, and
dizziness, and was diagnosed with Acute Myocardial Infarction (anterior wall), in November
2020. He was admitted for the same in the Male ward of the Cardiology Department of
IPGME&R and SSKM Hospital, Kolkata.
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2. He underwent Percutaneous Transluminal Coronary Angioplasty (PTCA) to LAD (Left
Anterior Descending Artery) on 28.12.2020 and was advised to follow up in the Cardiology
OPD at IPGME&R and SSKM Hospital from then onwards
3. 3. The patient had developed sudden onset unstable angina, accompanied by dizziness and
sweating in April 2022, and was again admitted to the Cardiology male ward of IPGME&R
and SSKM Hospital, Kolkata. He had again undergone PTCA in August 2022 and was told to
follow up in the Cardiology OPD as and when advised
4. 4. The patient had again undergone Coronary Angiography (CAG) on 10.01.2023 at
IPGME&R and SSKM Hospital, Kolkata
5. 5. He was diagnosed with Hypertension during the episode of AMI in November 2020, and is
on regular medications since then
PERSONAL HISTORY:
Family history: His mother died of Acute Myocardial Infarction (AMI) at 70 years of age.
His younger brother too died of AMI at 39 years of age
Addiction history: Tobacco smoking (cigarette/bidi) since 15 years of age. He smokes 2-3
cigarettes/day
Functional history: Bowel, bladder, sleep, appetite- Normal
Current medications:
• Tab. Aspirin (75 mg) 1 tab once daily x cont.
• Tab. Nitrocontin (6.4 mg) 1 tab twice daily at 8 am and 3 pm x cont.
• Tab. Rosuvastatin (20 mg) 1 tab once daily x cont.
• Tab. [Metoprolol (25 mg)+Telmisartan (40 mg)] 1 tab once daily x cont.
• Tab. Ranolazine (500 mg) twice daily x cont.
• Tab. Trimetazidine (60 mg) twice daily x cont.
• Tab. Esomeprazole (40 mg) 1 tab once daily on empty stomach x cont.
Personal hygiene:
• Bathes daily with soap and water.
• Cleans hair twice a week using shampoo and water.
• Wears clean clothes.
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• Trims nails twice a month.
• Uses slippers for walking.
Toilet: Care for self at the toilet completely; no incontinence.
Feeding: Eats without assistance.
Dressing: Dresses, undresses, and selects clothes from own wardrobe.
Grooming: Always neatly dressed, and well-groomed without assistance.
Physical ambulation: Goes about grounds or city.
Bathing: Bathes self without help.
Total ADL score: 6 (full function)
NUTRITIONAL ASSESSMENT:
CLINICAL EXAMINATION:
Date of examination: 18.05.2023
➢ General Examination:
Height – 1.6 m
Weight – 78.4 kg
BMI- 30.6 kg/m2
Blood pressure (mmHg) – 138/88
Pulse rate – 86/min
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Respiratory rate – 18/min
Pallor – Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Oedema - Absent
Neck glands – Not palpable
Tongue- Layered
Teeth- Clean
➢ Systemic Examination:
CNS – Conscious, alert, cooperative and oriented to time, place and person
Respiratory System – Bilateral basal crepitations heard
GI System – Abdomen soft, non-tender, non-distended on palpation. Intestinal peristaltic
sounds heard
CVS:
▪ Pulse-
o Rate: 86/min
o Rhythm: Regular
o Volume: Normal
o Comparison between two radial pulses: No delay
o Radio-femoral delay- Absent
o Other peripheral pulses- Palpable, no obvious abnormality
o Blood pressure- 138/88 mmHg
o Neck veins- Not engorged
o Examination of chest-
o Moving bilaterally equally with respiration
o No deformity or bulging of chest
o Superficial engorged veins- Absent
o Accessory nipples- Absent
o Scar mark- Present (midline of sternum)
o Epigastric or suprasternal pulsation- Absent
o Pericardial rub- Absent
o Auscultation of different areas of the heart-
o Mitral- NAD
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o Tricuspid- NAD
o Pulmonary- NAD
o Aortic- NAD
o Heart sounds- S1 and S2 audible
o Examination of the back- No obvious abnormality
CARE SEEKING BEHAVIOUR:
Usual source of care seeking: L.B. Dutta Rural Hospital (Muchisa) and IPGME&R and
SSKM Hospital, Kolkata
KNOWLEDGE AND PRACTICE REGARDING HEALTH DISORDERS THE PATIENT IS
SUFFERING FROM: (Respondent- Mr. Goutam Mondal)
Diseases/ Knowledge Practice
syndromes Causation/risk Symptoms Care- Prevention Care seeking Prevention
factors seeking
behavior
1. Eating too much Headache, Doctor Decrease intake On regular None
Hypertension of salt, oily and vertigo, sweating of salt, oily and medications
flesh food fatty food
2. CVD Eating too much Chest pain, Doctor Decrease intake On regular Restricted
of salt, oily and sweating, fatigue, of salt, oily and medications, salt intake
flesh food, HTN, breathlessness fatty food follow-up at
tobacco smoking IPGME&R
HOUSING:
Mode of possession: Own
Type of house: Mixed
Setback area: Present
Verandah: Present
Table. 1. Assessment of Overcrowding in the patient’s room:
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Criteria Observation Remarks
1. No. of persons per room Room 1 – 2.5 persons Overcrowding present
2. Per capita floor space Room 1= (7x6) sq. ft= 42 sq. ft Overcrowding present
3. Sex separation N.A. N.A.
Table. 2. Assessment of ventilation in the patient’s room:
Room Criteria (% of floor space) Remarks on
ventilation
Door area Window area (sq. Total area of Total floor
(sq. ft.) ft.) door and space area (sq.
windows (%) ft.)
1 (5x4)= 20= (3x3.5)+(2x2.5)= (47.6+36.9)= 42 Adequate
47.6% 15.5= 36.9% 84.5
Details of the room where the patient lived:
Cross-ventilation: Absent
Ventilation: Adequate
Natural lighting: Inadequate
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Kitchen: Present outside the room
Drainage system: Absent
Indoor air pollution: Absent
Breeding places for flies, mosquitoes and rodents: Absent in the room, but present outside
the house
WATER SUPPLY:
• Source of drinking water: Dakshin Roypur Water Project (Budge Budge-II Block)
• Mode of supply: Intermittent
• Distance of water source from the household: Outside household premises (approx. 2 ft.)
WASTE DISPOSAL
• Solid wastes (including kitchen wastes): Stored in plastic packets and then thrown into the
land adjoining a small pond, beside the house
• Liquid waste: Drained into the pond near the house
EXCRETA DISPOSAL:
• Type of latrine: Sanitary
• Possession: Own
• Distance from the house: ~2 ft
• Manual flushing.
• Cleaning: Once a week.
• Maintenance: Satisfactory
CLINICOSOCIAL DIAGNOSIS:
The patient under study is a 49-year-old uncontrolled hypertensive, obese male (Asian classification),
addicted to tobacco smoking and suffering from occasional exertional dyspnea and pain in B/L shoulder
joints, with a H/O of PTCA following Acute Myocardial Infarction (Anterior wall) 3 years back,
residing in his own, mixed house with inadequate natural lighting, inadequate cross-ventilation,
presence of overcrowding, breeding places of flies, mosquitoes and rodents around the house and
consumed a diet deficient in energy.
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ACTIONS TAKEN:
✓ The patient was advised salt-restricted diet (<6 gm/day or <1 tsp/day) and to avoid extra salt
with meals
✓ He was advised to avoid oily and spicy food
✓ He was told to consume low-fat milk and milk products like yogurt (DASH diet), groundnuts,
locally available, seasonal, fresh green leafy vegetables like spinach, pumpkin, gourd,
legumes, etc., and fruits in his diet
✓ He was advised to get his BP monitored at regular intervals at L.B. Dutta Rural Hospital, and
follow-up visits at Cardiology OPD of IPGME&R and SSKM Hospital
✓ He was explained about the harmful effects of smoking tobacco and was advised to attend the
Tobacco Cessation Clinic at Kolkata Police Hospital (under IPGME&R and SSKM Hospital)
every Thursday, between 12 noon-3 pm
✓ Investigations given:
o Blood for CBC, Lipid profile, Urea and serum for Creatinine
o ECG-12 leads
o Digital radiograph of B/L shoulder joints (AP and Lateral view)
o Digital radiograph of the chest (PA view)
✓ Medications given:
o Tab. Paracetamol (650 mg) 1 tab SOS
o Tab. Multivitamin (1tab) once daily x 1 month
o Hot compress to be applied to the shoulder joints thrice daily x cont.
o Diclofenac ointment to be applied locally twice daily x cont.
✓ He was also advised to attend the Respiratory Medicine OPD for his occasional exertional
dyspnea, Orthopedics OPD and PMR OPD at IPGME&R and SSKM hospital for his B/L
shoulder joint pain
RECOMMENDATIONS:
A. Individual level:
✓ The patient was recommended to adopt a healthier lifestyle by quitting tobacco consumption,
restricting salt intake and undertaking yoga and meditation
✓ He was advised to refrain from undertaking strenuous activities like lifting or carrying heavy
objects, running, fast cycling, etc.
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B. Family level:
✓ The patient and his family members were told to avoid stagnation of water around the house
and to keep the surroundings clean to avoid further development of breeding places for flies
and mosquitoes
✓ To use mosquito nets, mosquito-repellent creams, insecticidal sprays, etc.
✓ To keep the doors and windows open during the daytime for adequate natural lighting
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