1. 1. Presentor Dr Md Abu Bashar Junior Resident Moderator Dr Rajesh Kumar Professor & Head, SPH, PGIMER
2. 2. Family ProfileName Age /sex Education Occupation Income Health status Adi Mullam 60/M 5th educated BELDAR(CH AUKIDAR) in PWD 35000 Chronic Alcohalism with Uncontrolle d HTN MALIGA 50/F 5th class educated Mali(contract or) 8000 Painful Knee joints RAJVEL 30/M 8TH CLASS Mali (contract) 8000 Healthy KAMACHI 25/F 10TH HOUSEWIF E NIL Healthy MANI KAUSHAL 28/M 8TH CLASS PVT JOB 8000 Healthy RAJESHWA RI 5/F PRENURSERY - - ALLERGIC RASHES ? INSECT
3. 3. SES Middle middle class(III) a/c to modified Kuppuswamy scale Address - #3207/1, sec-38D, chandigarh Type of family joint family Living in chandigarh for last 40 years Originally from Asnoor village, distt.- Vunarbata(T.N.) Father migrated to Chandigarh in search of employment Earlier living in jhuggi in maloya now., living in govt provided 2 room flat of which premium is being paid
4. 4. Index case Adi mullam , 60/M, originally from TN living in chandigarh for past 40 years, regular employee of PWD, living in Sec-38D Chandigarh.
5. 5. Presenting Compliants Breathlessness on exertion *3 years Pain chest on & off * 2 year Tremors * 2 months Dizziness * 5 days Weakness & lethargy* 2 days
6. 6. History of present illness Patient is a k/c/o of hypertension for past 5 years Started developing breathlessness when he use to do heavy work & relieved by taking rest Also started having breathlessness after heavy drinking Start having chest pain on & off while doing work which subsided by its own Starts having tremors in hands which is not associated with any aggravating factors, especially increased after leaving alcohol for few days Feeling dizziness for past 5 days especially in morning alongwith weakness & lethargy
7. 7. Negative history No h/o syncopal attack or uncousiousness No h/o cough with expectoration No h/o generalized edema or decreased urine output No h/o orthopnoea/ nocturnal dysponoea No h/o of pain abdomen or ascites No h/o
8. 8. Past history One episode of severe breathlessness with dizziness & palpitation in August, 2014 Started after taking alcohol Contacted a local BAMS practi who after finding very high BP(200/120 mm of hg) referred to GMSH-16 Presented to casaulty and was given inj. Lasix along with tab. Telmisartan Admitted for two days Was discharged with tab. Dytor 10 mg OD, Tab.Amlodepin(5mg) OD, Tab. Metolar XR 25 mg OD, Tab. Clopitab A 75 mg OD, tab. Aztor 20 mg HS & Tab. Trika 0.25 mg HS
9. 9. Past history Was diagnosed with hypertension by a pvt BAMS practicenor and started on treated in 2010 Irregular in drug intake Mostly takes drug when have dizziness or headache Other drugs for breathlessness & chest pain is also being given by the practioner
10. 10. Family history H/o increased BP was found in elder brother who was an chronic alcohalic too along with chronic smoker Died of heart attack 10 years back No family H/o diabetes, asthma or TB
11. 11. PERSONAL HISTORY Chronic alcohalic for past 40 years Daily intake various from 180 ml to 320 ml of alcohal/d in form of whisky Chronic tobacco abuser in form of khaini & zarda. Mostly drinks alone at home after work but occasionaly takes drink before going to work too Non- vegitarian Regular abseinitism from work due to alcohalism
12. 12. Psychosocial History Never thought to quit alcohol Skips only when he didnt have money Regular drinking since early adulthood Worried for his health but doesnt relate it to alcohol Family members wants him to quit alchohal & are too much disturbed due to his habit As told by daughter-in-law, jab ye jayda pee lete hai to duty bhi nhi jate, din bhar sote rehte & bed pe hi urine bhi kar dete hai He use to take a part of salary for himself and gives rest money to his wife for famiy expenditures but ask for money in between too and even borrows money from friends & neighbours Concerned parent & want to get regular jobs for them for his sons Have good relation with neighbours & never disturbs them while drunk
13. 13. Environmental & housing condition Living in government provided 2 room flat with separate kitchen & toilet Ventilation & cross ventalation- adequate Lighting inadequate Drinking water filtered water Source of cooking LPG Flies , mosquitoes & Rats absent Toilet Indian style Overall hygiene- good Indoor air pollution-absent
14. 14. Dietary history a/c to 24 hours recall method, total calorie intake is 1800 kcal & 28 gms of protein from food 600 Kcals from alcoh0l Total salt intake> 5 gms/d
15. 15. Treatment Seeking Behaviour For minor illnesses, use to go to a local BAMS practitioner and use to take medicines from his clinic only Coming to PHD-25 for treatment for last 6 months For major illnesses, use to go to GMSH-16 Never contacted any traditional faith healer or took Desi medications.
16. 16. Examination
17. 17. General examination Pt conscious, oriented to T/P/P GC- average Pulse -82/min BP-160/94 mm of Hg Temperature - Afebrile Weight 56 Kg , height 54 BMI 17.5 Waist circumference- 32 Waist/hip ratio- 0.7 Pallor Mild Icterus, clubbing, cynosis, l.adenopathy, edema absent JVP not raised Thyroid not enlarged
18. 18. Systemic examination Respiratory system Inspection trachea central, chest wall symmetrical, moving equally with respiration Palpation- no chest wall abnormality felt, no tenderness present Percussion resonant note found all over chest wall Auscultation normal vesicular breath sounds, Air entry equal on both side, no rhonchi heard with fine basal crepts +nt
19. 19. Systemic examination Cardiovascular system Inspection jugular veins not engorged Palpation- apical impulse felt in left 5th intercostal space Auscultation S1 S2 normal, no murmur heard
20. 20. Systemic examination Nervous system A. Global & Functional assessment Katz ADL is the most appropriate tool to assess it. A score of 6 indicates full function, 4 moderate impairment and 2 or less severe functional impairment
21. 21. Katz index of independence in ADL PT SCORE ON ACTIVITIES POINTS(1 OR 0) INDEPENDENCE(1 POINT) NO supervision, direct or personal assistance DEPENDENCE (0 POINT) WITH supervision, direct, personal assistance or total care BATHING POINTS - 0 (1 POINT) Bathes self completely or needs help in bathing only a single part of body (0 POINT) Needs help in bathing more than one part of body. Requires total bathing DRESSING POINTS -0 (1 POINT) Gets clothes from closets and puts on clothes complete with fasteners (0 POINT) Needs help with dressing self or need to be completely dressed TOILETING POINTS -0 (1 POINT) Goes to toilet, gets on and off, clean genital area without help (0 POINT) Needs Help transferring to the toilet, cleaning self or uses bedpan or commode TRANSFERRI NG POINTS - 0 (1 POINT) Moves in or out bed or chair unassisted. (0 POINT) Needs help in moving from bed to chair CONTINENCE POINTS- 0 (1 POINT) exercise complete self control over urination or defecation (0 POINT) Is partially or totally incontinent of bowel or bladder FEEDING (1 POINT) Gets food from plate into (0 POINT) Needs partial or total8/10/2015 21
22. 22. Nervous system examination Motor system Power Right upper limb- 5/5 Left UL-5/5 right lower limb- 5/5 Left UL -5/5 Tone- normal in both upper & lower limbs Bulk of Muscles- normal in both upper and lower limb Gait staggering gait Reflexes - Superficial reflexes- normal Deep tendon reflexes normal Sensory system Normal Cranial nerve examination normal 8/10/2015 22
23. 23. Nervous system examination Higher mental functions Memory- impaired Orientation oriented to time/place/person Judgement intact Speech hesitancy in word production, difficulty in articulation, normal fluency 8/10/2015 23
24. 24. Investigation done TLC, DLC, ESR,HB, Platlet count Normal(18/08/14) R/E- Pus cells -1-2/hpf, Epithelial cells-1-2/HPF ECG done twice T-wave changes X-ray grossly normal USG KUB(16/08/14) normal study for b/l kidneys USG whole abdomen not done
25. 25. Provisional Diagnosis A 60 old Hindu non vegetarian male belonging to 6 member family of middlemiddle class a/c to modified kuppuswamy scale, k/c/o hypertension for past 5 years currently uncontrolled with poor compliance to treatment & chronic alcohalism with tobacco chewing for past 40 years currently suffering from breathlessness on exertion along with tremors & mild anaemia
26. 26. Management Individual Management Investigations USG whole abdomen to detect Chronic liver disease/ cirrhosis Kidney function tests t/t Tab. Amlodepine(10 mg) 1 Tab BD Tab. Metolar XR 5 mg OD Tab. Clopitab-A 75 mg OD Tab. Aztor 20 mg HS Ensuring compliance to medications Psychiatry consultation for de-addiction
27. 27. JNC-8 GUIDELINES FOR HYPERTENSION
28. 28. MANAGEMENT Individual level Lifestyle changes - complete absteinance from alchohal & tobacco chewing - regular exercise for 30-40 min./d - Reduced salt intake(>5 mg/d)
29. 29. Management At family level - Screening for all family members for hypertension - Positive family support for quitting alcohol - Reduced salt intake - Include 5 servings per week of fruits by all family members - Ensuring compliance of medications by the patient
30. 30. Management at community Level
31. 31. Management at Community level National Programme for control of Cancer, Diabetes, Cardiovascular diseases and Stroke(NPCDCS) National Programme for healthcare of elderly(NPHFE) De-addiction centres Creating awareness about prevention of NCDs & alcholism Sensitization of community towards need of alchohalics Community based management of substance abuse Rehabilitation measures 8/10/2015 31
32. 32. NPCDCS 8/10/2015 32
33. 33. NPCDCS Tobacco, alcohol, unhealthy diet ,physical inactivity, high salt intake, high BP & obesity are major risk factors common to many NCDs. Keeping in view that there are common preventable risk factors for Cancer, Diabetes, CVD & Stroke, GOI initiated it during 2010-11 Focus of NPCDCS is on promotion of healthy life styles, early diagnosis & M/m of diabetes, HTN, CVD including stroke & common cancers Implemented in 100 pilot districts across 21 states during 2010-12. 8/10/2015 33
34. 34. NPCDCS Activities consists of opportunistic screening of persons above the age of thirty years for diabetes and hypertension ,at the point of primary contact with any health facility Each District hospital will have regular NCD clinic for screening, management , and counseling & awareness generation for NCDs 6-10 bedded Cardiac care Unit(CCU)/ICU would be established in at least 25% DHs. The districts will be supported with certain essential drugs including TPA for stroke patients 8/10/2015 34
35. 35. National Programme for Health Care of Elderly(NPHE) NPHCE is an articulation of the International and national commitments of the Government as envisaged under the UN Convention on the Rights of Persons with Disabilities, National Policy on Older Persons & Section 20 of The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 The Vision of the NPHCE are: To provide accessible, affordable, and high-quality long-term, comprehensive and dedicated care services to an ageing population; Creating a new architecture for Ageing; To build a framework to create an enabling environment for a Society for all Ages; To promote the concept of Active and Healthy Ageing. 8/10/2015 35
36. 36. Strategies for achieving objectives of NPHE Community based PHC approach including domiciliary visits by trained health-care workers Dedicated services at PHC/CHC level including provision of machinery, equipment, training, additional human resources, IEC etc. 10 bedded wards for elderly at District Hospitals Strengthening of 8 Regional Medical Institutes to provide dedicated tertiary level medical facilities for the elderly, introducing PG courses in geriatric medicine, and in-service training of health personnel at all levels IEC using mass media, folk media and other communication channels to reach out to the target community Continuous M & E of the Program & research in geriatrics Promotion of public private partnerships in geriatric health-care Mainstreaming AYUSH Reorienting medical education to support geriatric issues. 8/10/2015 36
37. 37. COMMUNITY BASED MANAGEMENT OF SUBTANCE ABUSE DISORDERS
38. 38. NEED & RATIONALE Community based treatment and prevention approach emerged as a key strategy to reach vulnerable groups The rationale behind the approach is that treatment process is brought closer to alcohol/drug affected individuals and afflicted families, who may not be able to avail these facilities on account of social stigma and
39. 39. Advantages of CBT The National Institute on Drug Abuse (NIDA, USA) stresses that while the ultimate goal of all drug abuse treatment is to enable the abuser or addict to achieve lasting abstinence, there are important immediate goals as well. These are: To reduce drug use, Improve the patients ability to function, & To minimize the medical and social complications of drug abuse. The envisaged goals of community-based treatment remain the same but the emphasis is on: Detoxification of a selected group of alcohol and drug dependents in a locality/catchment area. Re-establishment of family bonds and reintegration of detoxified Persons with their community Creation of awareness in the community of the existence of alcohol and other problems in their environment Development of a sense of responsibility on the part of the public and voluntary organizations in supporting the process of t/t & rehabilitation Encouragement to the client commence rehabilitation with confidence
40. 40. COMMUNITY MOBILIZATION Steps to be taken: Formation of core group of representatives from different walk of life, including health/welfare personnel, religious leaders, parents groups, business and trade group, educators, trade unions, women/youth groups, enforcement personnel and local officials. The group helps in assessment of problems, need assessment and formulation of local action plan. Community support : The activities may range from creating drug free zones for marginalized groups, social acceptance and reintegration. The community volunteers, ex-users and family members and core group and community based organizations (CBOs) play a significant role Institutional network: Government agencies :In a given community, a large number of central and state agencies operate in different spheres and their available resources can provide a big platform for community intervention.
41. 41. STRATAGIES Organized treatment: rehabilitation and reintegration for physical/psychological dependence on drugs. (Continuum treatment services in community set up.) These include: Detoxification is a 5 to 30 day treatment intended to wean the user from his or her substance. it can be done in a hospital-like setting or in a community based program. Residential settings usually treat patients for 14 to 28 days Outpatient. Frequently alcohol/drug dependence is treated in an outpatient setting. Some people receive care in day treatment programs, where they attend treatment for part of the day but spend night at home
42. 42. Treatment settings A. Centre Based Treatment extending to community: A drug affected community/specific groups are adopted by De-Addiction Centre/ Medical Institute/ College and substance abusers are referred to these services for detoxification and management of concurrent illness. After completion of a treatment regime and psychosocial treatment, the patients are sent back to their community and a community team monitors, involves the family to prevent relapse and manages other problems including any crisis B. Community based treatment at district level: Civil/District hospital provides treatment services and medical colleges/ institutions and the Ministry of Health act as agencies for execution, advice and monitoring. The district bodies do the actual implementation. Each district can have a local coordination committee to carry out various activities. By and large, the district committees are headed by District Magistrates
43. 43. Treatment Settings contd C. Community clinic/Outreach services: set up in the natural milieu. Its broad objectives are: To identify majority of drug dependents in main catchment areas and adjoining localities and to initiate the process of pre-treatment counseling (clarify myths and misconceptions associated with drug abuse. To focus on health and social consequences of socially sanctioned drugs like alcohol and tobacco as well as illicit drugs such as heroin and psychotropic drugs in their environment and suggest possible remedial steps To provide low cost treatment services within community To facilitate formation of local support groups (youth, women, etc.) as well as self-help groups (AA, NA, etc.)
44. 44. Treatment settings D. Camp Approach : Camp approach emerged as a key approach in the context of opium and alcohol treatment, especially in the rural areas. It involves identification of all drug dependent persons living in a locality, mobilization of ex-users and volunteers for assistance in the detoxification camp, use of premise (community center, empty schools or other institutional premises) for 10-14days. Even after detoxification process, care providers maintain contact fairly over a long period of time to assure that momentum is not lost and community continues its vigilance and helps in relapse prevention E. Field Post Used to make an access to hard-to reach populations - truck drivers, migrants, sex workers, street children and homeless useful tool for targeting risk behavior- ID use practices, unprotected sex and HIV/AIDS Outreach team gains alliance with key people. After gaining access to hidden population, risk reduction interventions can be carried out to target their risky behavior. The approach helps in making regular and close contact with at risk population and helps in identifying drug users, who can be trained as peer counselors and help in implementing harm reduction activities
45. 45. Integration & Collaboration Involving govt medical institutions/health infrastructure involvement of local NGOs, self- government bodies (Panchayat, Zila Parishad), office of the district administration, District Magistrate (DM), Sub-Divisional Officer (SDO), Block Development Officer(BDO), Community Development Officer (CDO) and personnel engaged in agriculture extension and rural development In urban areas state/central government agencies like urban basic service, ICDS, municipal bodies and health and welfare care network and resources can be tapped to strengthen the services at community level The enforcement officials, (Superintendent of Police), office of the Deputy Narcotics Commissioner (DNC) can be part of community based intervention treatment. Emphasis is to involve officials from both demand and supply reduction activities.
46. 46. Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low- Resource Settings
47. 47. ORIGIN The implementation plan of the Global Strategy for Prevention and Control of NCDs was endorsed by the World Health Assembly in May 2008. The objective 2 of the NCD Action Plan highlights the need to establish national policies and plans for NCD prevention and control. As one of the key components of this objective, WHO is called upon to provide technical guidance to countries in integrating cost-effective interventions against major NCDs into their health systems Furthur, the Action Plan proposes that Member States implement and monitor cost-effective approaches for the early detection of cancers, diabetes, hypertension and other cardiovascular risk factors and establish standards of health care for common conditions like CVD, cancers, diabetes and chronic respiratory diseases integrating when ever feasible their management at PHC
48. 48. PUBLIC HEALTH SOLUTIONS Infancy: EBF for six months Nutrionally ADEQUATE & SAFE complimentary feeding after 6 months Childhood and adolescence: Improve life skills education; Physical activity in school and society; Safe and healthy foods in schools; Restrict marketing of and access to food products high in salt/sugar/unhealthy fats; Institute tobacco and alcohol controls. Adulthood: Improve maternal nutrition; Implement tobacco prevention and cessation programmes; Improve availability and affordability of food; Encourage physical activity (worksites, urban design); Provide access to effective prevention and care of risks and diseases.
49. 49. Components of PEN Tools for assessment of gaps, facilities & utilization of primary care Tool for assessment of population coverage of NCD care Templates to collect health information Evidence based protocol for essential NCD intervention for PHC Core list of essential technologies & medicines Tools for cardiovascular risk prediction Tool for auditing & costing Tools for M& E Training material Aids for self care
50. 50. Technology & tools for essential NCD intervention at Primary level Technologies Tools Thermometer Stethoscope BP device Weighing machine Peak flow meter Spacers for inhalers Glucometer Blood glucose test strip Urine protein test strips Urine ketone test strips WHO/ISH risk prediction charts Evidence based clinical protocols Flow charts with referral criteria Patient clinical record Medical information register Audit register Add when resources permit: Nebulizer Pulse oximeter Blood cholesterol assay Lipid profile Serum creatinine assay Troponin test strips Urine microalbuminuria test strips Tuning fork Electrocardiograph(if training to read and interpret
51. 51. 8/10/2015 51