All clinico social formats

SUGGESTED FORMAT FOR CLINICO-SOCIALCASE PRESENTATION
1. DemographicDetails:
Name: Age: Sex: Religion and caste:
Education: Occupation: Address: Marital status:
Nearest health facility: Mention pregnancy and Obstetric formula (if applicable):
2. Presenting complaints:
3. Historyof presenting illness including treatment availed till date:
Briefly describe the onset, progression and treatment availed in chronological order. Probe
for the places of treatment, who helped decide the places of treatment and the reasons for
that, the expenditure incurred so far and the satisfaction with the services. Also identify any
reasons for delay in seeking services and failure of early diagnosis and treatment. Include the
details of chronic conditions such as diabetes and hypertension here.
4. Relevant past history: past surgeries, illnesses, blood transfusions, allergies or trauma.
Additional important details (as relevant to the case):
a). Menstrual & marital history b) Antenatal (obstetric) history c)
Natal& postnatal history d)Immunization history e) Milestones
f) Contraceptive use
5. Personal history: a) Addictions: Alcohol/Tobacco/Drugs b) Bowel& bladder habits:
6. Family history: a) Family type b) Family composition (draw a family tree)
c) History of consanguinity d) Family
relationships e) Response of family towards the illness
7.Environment: a)Housing: pucca /semi-pucca /kutcha b)Overcrowding: present/ absent
c)Toilet facilities d) Methods of waste disposal
e) Drinking water supply f) Animals/ Pets
g)Occupational environment (inspect if possible)

8.Socio-economic history:
A. Interaction with society: response of society towards the person, presence of stigma,
participation in festivals, marriages and other social activities, involvement in social
groups
B. Economic conditions:
a)Total family income b) Expenditure on diet and medical care
c) Savings or debts d) Family tensions due to the economic situation
C. Contacts(for communicable diseases):Family /social /workplace
9. Nutritional history (as relevant to the case):
a) Vegetarian/Non-vegetarian
In case of children, ask the time taken after birth to initiate breastfeeding, if any pre-
lacteal feed was given, duration of exclusive breastfeeding, any problems in
breastfeeding, complementary feeding(age of starting and foods used for starting),
feeding practices(feeding frequency, type of food, amount, bottle-feeding)etc.
b) 24-hour diet recall (tabular format for breakfast, lunch, evening snacks & dinner)
Total daily calorie
intake:
_, Classify as: deficient /adequate /excess
Total daily proteinintake: _, Classify as:deficient/adequate/excess

c) Customs and beliefs pertaining to diet
d) Comment on type of food intake: high salt, high fat, fibre (fruits & vegetables), refined
carbohydrate(sugar, starchy foods);habit of eating outside.
10. General examination and relevant systemic examination.
11. Anthropometry: height, weight, head circumference, symphysio-fundal height, BMI etc.
11. Laboratory investigations already done and planned in future.
12. Clinico-social diagnosis:
Mention the clinical diagnosis. Summarize all the relevant positive and negative clinico-social
aspects explaining the influence of family, social and environmental factors on the cause,
course, consequence and treatment of the disease.
13. Suggestacomprehensivemanagementplanrelevanttothediagnosedcondition:
Levelsof
prevention
(modes)
Primary
(health promotion
and specific
protection)
Secondary
(early diagnosis &
treatment)
Tertiary
(disability limitation
and rehabilitation)
Individual ………. ………… ………..
Family ………. ………… ………..
Community ………. ………… ………..

1 | A N C _ D r S i t a n s h u S e k h a r K a r _ J I P M E R
ANC/ PNC Format
Brief information of the reference person of interest
Name: Age: Husband’s name:
Education: Age at marriage:
Blood group and Rhtype: Gravida: Para: Living: Abortions:
MTP:
Family Folder Number:
Details of the family members
Family Tree
PRESENTPREGNANCY–
(I)ANTENATALCARE
1. Timeof registration(inmonths)
2. Confirmationof pregnancy:UPTathome/athealthcentre/other
3. Sourceof Antenatalcare
4. No.of Homevisits
5. Antenatalperiod
Trimester 1:
 Registration details
 Excessive vomiting; Bleeding p/v; fever with rashes;
 Drug intake
 Weight gain -*
 Investigations-Hb; USG , blood group, VDRL, Hep-B,
 Folate supplementation *
 TT
Trimester 2:
 Quickening
 Weight gain
 Blurring of vision; epigastric pain; pedal edema; headache;
 Iron and calcium supplementation- whether taking daily or not *
 Side effects because of IFA supplementation-Nausea; vomiting; loss of appetite; change in the
colour of stools
 Hours of sleep/rest-afternoon and night
 Tetanus toxoid immunization
 Investigations-Urine albumin, sugar, microscopy; Hb*
Trimester 3:
 ANC visits; Weight gain
 Warning signs-

 Pain abdomen;
 Decreased perception of fetal movements;
 ( Normal*) Leaking / Bleeding pv;
EligibilityforcashbenefitunderJSY/anyotherconditionalcashtransferscheme
7.Utilizationof Anganwadiservices:
Ifyes,whatservices,howfrequently? Ifno,why?
8.Highriskstatus
Elderlyprimi Shortstature Malpresentation
AntepartumHemorrhage Pre–Eclampsia&Eclampsia SevereAnemia
Hydramnios Grandmulti/para Twins
Historyof previousC section Previousstill-birth,IUD,abortions Treatmentfor infertility
Associatedwithgeneraldiseases(CVD,kidneydisease,Diabetes,TB,liverdisease,malaria,convulsions,asthma,
HIV,RTI/STI,etc)
9.Followupdetails of Important Events:
Time of visit
Health facility visited
Advice / treatment given
B.P.
Pallor/ Hb%
Edema
II.INTRANATALCARE
Dateof delivery/abortion/MTP: Placeof delivery/MTP:Home/ institutional(HSC/PHC
/CHC/Private)
Typeof delivery-Vaginal/C-section/Instrumental Anycomplications
Attendedby No.of daysof hospitalization
Outcomeof Pregnancy-SpontaneousAbortion/MTP/Stillborn/Livebirth
Babydetails:
Sex Weight: Length:
Criedatbirth: Birthinjury: Congenitaldefects:

III.POSTNATALCARE
Mother Baby Remark
Date Temp Lochia Fundus Lactation General
Condition
Cord Feeding Bowel
Homevisitsduringpostnatalperiod:
IV. PASTOBSTETRICHISTORY
No Date Place
Pregnancy Labor
Puerperium
Infants
AN
Health
Maturity Duration
inHrs
Delivery
Type
Live/
Stillborn
Wt Sex Present
Health
V.FAMILYPLANNING
1)Dothecoupleknowthatit ispossible
Husband:Yes/NoWife:Yes/No topreventorpostponepregnancy?
2) Aretheyawareof anymethodsof Husband:Yes/NoWife:Yes/No
Preventingorpostponingpregnancy?
3)Ifyes, whichmethod(s)?
4) Attitudetowardsfamilyplanning HusbandWilling:Yes/No
WifeWilling:Yes/No

5) Aretheypracticinganymethods? Yes/No
Ifyes, whichmethod?
Ifno,didtheyeverpractice? Whichmethod?
Describehowtheydecidedonaparticularmethodandreasonforchanging,ifany.
6) Aretheysatisfiedwiththemethodused?Ifno,givereasons.
VI.SEXUALLYTRANSMITTEDINFECTIONS
a) Condition
b) Receivedtreatmentfor STI - Y/N
c) Placeof treatment - Public/Private
d) Husbandtreated - Y/N
VII. Past History
VII. Menstrual History
VIII. Marital History
When / consanguinous or not / Inter-caste marriage / any problem in family
IX. Personal History (including occupational History)
- Addiction
- Hygiene
- Appetite/ sleep
- Emotional support
- Type of work
- Nature of work
- Duration of work continuation of work during pregnancy
- Wages
X. Diet history
XI. Family History
XII. Environmental History
- Housing
- Water supply
- Hygiene-sanitation
- Hazards at the house
XIII. Economic condition
- Total income
- Ration card use
- Use of PDS
XIV. Social welfare measures
- PDS
- JSY

- Anganwadi
- SHG
XV. Customs observed / cultural practices
- Valagaapu ceremony
- Dietary changes
- Knowledge attitude and practices regarding nutrition, child care, contraception
XVI. Examination
XVII. Summary
Mrs X, ------ year old, married since------------, is currently in 1
st
/ 2
nd
/ 3
rd
pregnancy in ------month of
gestation with ------ such complaints (high risk or not) is palnning for safe confinement in ______ center.
Positive and Negative Factors
Level of failures
Comprehensive Diagnosis
Include physical, mental and social dimensions
XVIII. Management
- Individual
- Family
- Community

1 | Dr Sitanshu_U5 Child
Case of an Under 5 child: Proforma
Details of the family and case of interest:
Sl no Name Age Relation to HoH Education Occupation
Socio economic status:
a) Occupation (in case of retired person last occupation he was engaged in)
 Ask about the nature of work
 whether in govt or private sector
 availing any social security schemes
b) Education
c) Family income
Socioeconomic status:
Per capita income:
(APL/BPL)
Enquire about the ration card
Index case:
Informant: Reliability:
Chief complaints: Failure to gain weight
Fever, cough, Respiratory difficulty, diarrhea, symptoms suggestive of measles
Presence of danger signs like convulsions, loss of consciousness, inability to
feed
History of presenting complaints: Elaborate the chief complaints. Enquire about other complaints.
Ask about h/o
 recurrent infections(respiratory and skin to be specially enquired)
 worm infestation
 decreased appetite
 chronic conditions especially TB
 Ear discharge
Past History:
 Hospitalisation
 Measles
 Chickenpox
 ARI/Diarrhea
Treatment history: undergoing any treatment for chronic condition, for the present condition, h/o
treatment in the past, past hospitalisation.
Birth History:
 Term/preterm

 Normal/assisted/CS
 Birth weight
 Incubator/NICU care
 Pre Lacteal feeds
 Time of initiation of breast feeding
 EBF till what age
 Time of start of complementary food, nature of complementary food
 H/o use of artificial feeds
Ante natal, natal and Post natal history:Trimester wise history 1st, 2nd and 3rd. Weight gain during
pregnancy, increased food intake during the pregnancy.
Complications during pregnancy like
 hyperemesis
 pre eclampsia
 eclampsia
 infections
 pre term delivery
 ante partum hemorrhage
Investigations done during pregnancy:
 Hemoglobin estimation,
 blood grouping,
 ultra sound scanning.
Developmental history:
a) Gross motor
b) Fine motor
c) Language
d) Personal social
Immunisation history: vaccines given appropriate for age, BCG scar, (reports of immunisation like
immunisation card to be seen), ascertaining whether measles vaccine and vitamin A given, delay in
immunisation and the reason for delay, optional vaccine administered.
Nutrition history:
24 hour diet recall:
a) Breakfast
b) Lunch
c) Evening snacks
d) Dinner
Calories and protein calculation:
Required
Actually consumed
Deficit
Anganwadi services utilisation:
Family history: h/o chronic condition in the family especially tuberculosis, h/o other children of the
family, h/o contraception usage by the couple.
Environmental history:

Housing: Apart from the routine special focus on following is needed
 Ventilation/Indoor air pollution
 Cleanliness
 Baby proofing
Economic history:
 Total income and expenditure balance
 Do not forget expenditure on education
General physical examination:
Evaluation of pallor, icterus, cyanosis, clubbing, pedal edema, lymphadenopathy.
Anthropometry:
Parameter Observed Expected Deficit
Weight
Height
MUAC
Head to toe examination to look for evidence of PEM likefontanneles, eye changes, skin infections,
dermatosis, hair changes, nail changes, signs of rickets like pot belly, wrist widening, richaty rosary,
harrisons sulcus, bow legs, knock knees. Oral cavity examination for dental hygiene and assessing
dentition.
Also keep in mind the IMNCI format.
Systemic examination:
a) Cardiovascular system
b) Respiratory system
c) Per abdomen
d) Central nervous system
KAP study:
a) Health visits by FHWs
b) Importance of weight gain
c) Vaccination and supplementation
d) De worming
e) Anganwadi and supplementary nutrition
f) Method of preparing ORS
g) Home available foods
h) Health seeking behaviour
i) Recognition of danger signs
Family diagnosis:
 type of family
 SES

 APL/BPL
 Grade of PEM
 Status of immunisation
 Disease if any
 Eligible couple
 Social problem
Interventions:
Level of prevention Primary Secondary Tertiary
Individual
Family
Community
a) Immediate: clinical management of any existing condition, de worming, dietary advice.
b) Long term: personal hygiene, vaccination, vitamin prophylaxis, nutritional advice, weight
monitoring, anganwadi service utilisation, family planning choices, importance of birthspacing.

1 | NCD_Dr Sitanshu Sekhar Kar_JIPMER
NCD
Name:
Age:
Sex:
Religion:
Caste:
Address:
Migration: from duration
Reason for migration:
Details of the family:
Sl no Name Age Relation to HoH Education Occupation
Socio economic status:
a) Occupation (in case of retired person last occupation he was engaged in)
 Ask about the nature of work
 whether in govt or private sector
 availing any social security schemes
b) Education
c) Family income
Socioeconomic status:
Per capita income: (APL/BPL)
(urbandelhi cut off for BPL is Rs. 612)
Enquire about the ration card/BPL card
Receiving Old age pension scheme?
 Expenditure on various items –
 Food –
 Rent –
 Electricity and other bills –
 Drugs and hospital fee – etc.,
Comment on the proportion of expenditure on treatment.
Chief complaints: History of any possible complications of Diabetes/Hypertension like chest pain(MI or
Angina), paralysis(stroke), foot ulcer (Diabetic foot), diminution of vision (Diabetic retinopathy) , change in
frequency of micturition (Nephropathy) etc.,
History of presenting complaints:
Diagnosis of disease –
 Coincidental or accompanied by typical symptoms
 Where was it diagnosed?
 What tests were done?
 Was the patient referred elsewhere?

Treatment history:
 Advice given by the physician – Including dietary and lifestyle advice
 Frequency of routine check-ups – Routine blood sugar, eye check-up, renal profile, foot examination
and lipid profile
 Change in the blood sugar or blood pressure over time – What was the patient informed?
 Change in the drugs – the number, type and dosage?

 History of any complications – ask for hospital admission
 History of self-care –
o History of missed doses
o Self -blood sugar check up
o Compliance to dietary advice
o Compliance to advice on physical activity
o Foot care
o Regularity of follow up visits
 Any other co-morbid conditions
Nutrition history:
24 hour diet recall:
a) Breakfast
b) Lunch
c) Evening snacks
d) Dinner
Calories and protein calculation:
Required
Actually consumed
Deficit/Excess
Ask for intake of fibre rich foods like leafy vegetables and fruits
Family history: Family history of Diabetes, Hypertension. Family support to the patient with the disease –
preparing appropriate diet, reminding about intake of drugs, accompanying for follow up visits etc.,
Environmental history:
a) Housing: type, no. of living rooms, no. of persons, overcrowding,
b) Type of flooring, any housing structure that might lead to foot injury
c) Ventilation:
d) Lighting
e) Drinking water: source, storage, method of retrieval.
f) Personal hygiene: frequency of bathing, brushing teeth, cutting nails, practice of wearing chappal.
g) Sanitary latrine: present/absent
h) Waste disposal:
General physical examination:
Evaluation of pallor, icterus, cyanosis, clubbing, pedal edema, lymphadenopathy.
II. Physical Examination
Height:
Weight:
BMI:
Waist Circumference: Waist Hip Ratio: Pulse: BP:
General Examination (build, skin, hair, marks of identification)

Personal Cleanliness: Nails: Mouth: Dress: Bathing Habit: Locomotion: (Flat Foot,
Knock Knee, Skeletal Deformity, Muscular wasting etc.)
Visual acuity - (R) (L) Night blindness
ENT (Hearing problem, Discharge)
Teeth and Gums (Number of caries, bleeding gums, etc.) Examination of lips, tongue, eye for deficiency
diseases
Systemic examination:
a) Cardiovascular system
b) Respiratory system
c) Per abdomen
d) Nervous system examination –
a. Foot examination – Look for any loss of sensation, foot ulcer
III. Laboratory Examination
Hb in gm% DC Peripheral smear Urine: Alb/Sugar/ME Blood Sugar
S. Urea S. Creatinine
Lipid profile – LDL etc., Any specific investigation done (Serological, X-ray,etc)
Other tests as deemed fit:
Activities of Daily living
Minimental status examination – for Dementia
GHQ12 / SF12
NCD RISK FACTOR Evaluation
DIET:Consumptionoffruitsandvegetables
Inatypical week,on howmanydaysdoyouconsumefruits?
Inatypical week,on howmanydaysdoyouconsumevegetables?
PHYSICALACTIVITY
Doesyourworkinvolve anyof
theseactivities
foratleast10min continuously
Workrelatedactivity Travel Recreational
Vigorous-intensity
[heavyloads,
digging,const.work]
Moderate-intensity
[briskwalking,
carryinglightloads]
Mild intensity
Travelto&from
places[walking or
cycling]
Sports,fitness
activities[walking,
cycling]
Numberof days/week
Howmuchtimedo you
spenddoingtheseon a
typicalday?
ALCOHOLUSE
Thefollowingquestionsareaboutalcoholicdrinks,i.e.beers,wines,spiritsandarrack
1)Haveyoueverhadanalcoholicdrink? 1.No 2.Yes
2)Abouthowoldwere youthefirsttimeyouhadan alcoholicdrink?_yearsold (WRITEIN)

3)Whendidyou lasthaveanalcoholicdrink?
4)Onhowmanydaysinthepast30dayshave youhadan alcoholicdrink?
Days
5)Thinkbackoverthelast30days,howmanytimeshave youhad>5 drinksinarow?
6)Onthedaysthatyoudrankduringthe last30days,abouthowmanydrinksdidyouusuallyhavea
day?Usualnumberof drinks:_
CIGARETTESANDOTHERTOBACCOUSE
Thefollowingquestionsareaboutcigarettesandothertobaccouse.
1) Haveyoueversmokedcigarettes(includinghandrolledcigarettes)?
2) Howoldwere youwhenyoufirstsmokedacigarette?
Yearsold
3) Howmanycigarettesadaydidyousmokeinthepast30days(orpastmonth)?
4) Haveyoueversmokedcigarettesdailyfor6monthsormore? 1.No 2. Yes
5) Forhowmany yearsdidyousmokecigarettesdaily?years
6) Haveyoueversmokedanyform of tobaccootherthancigarettes(e.g.pipetobacco,etc.)?
7) Howoldwere youwhenyourfirstsmokedanyformof tobaccootherthancigarettes?
8) Haveyoueversmokedatobaccoproductotherthancigarettesdailyfor6monthsormore?
*WorldHealthOrganizationSTEPSforNCDRiskfactorsurveillance
Impact of the condition on
1. Self –
a. Economic/
b. self-confidence/
c. Mental status/
d. Attitude towards life/
e. Why Me syndrome?
2. Family –
a. Economic- Debt,
b. Social isolation, participation in social function,
c. Impact on Social Network
3. Community
a. Disease/ health condition Group/
b. Social security issues

WHO/ISH Riskprediction charts
Figure1:10 yearriskofa fatalornon-fatalcardiovasculareventbyage,gender,systolicblood
pressure,totalbloodcholesterol,smokingstatus& presence/absenceofdiabetes

Family Diagnosis:
 type of family
 SES
 APL/BPL
 Disease with/without complication
 Social problem
 Mental problems
Interventions:
a) Clinical management
b) Dietary and lifestyle advice.
c) Routine check-ups
d) Family level – Support for compliance to the medical and lifestyle advice
e) Community level – Programs for primary, secondary and tertiary intervention

1 | TB_Dr Sitanshu Kar_JIPMER P a g e
TUBERCULOSIS Case format
1. Demographic characteristics:
SL
No
Name and Relation to
the index case
Age (years) Sex Education status Occupation
Socio economic status (Kuppuswamy classification)-
2. Family tree
3. History of presenting complaints:
a) Presenting complaints-
b) Duration of cough- *
c) Expectoration-
d) Hemoptysis-
e) Evening rise of temperature-
f) Weight loss-
g) Loss of appetite-
h) Lymph node enlargement-
i) Presence of any sinus/fistula-
j) Discharge-
k) Any deformity/pain/rigidity in any joints-
l) Headache/nausea vomiting/neurological symptoms-
4. Past history:
a) H/o contact –Neighbor/family/work place-
b) H/o Diabetes mellitus-
c) H/o HIV/AIDS-
d) H/o BCG vaccination-
5. Treatment history:
a) First contact person for the above complaints-
b) When was the sputum examination done-
c) Place where the sputum examination done-
d) When did you receive the results-
e) Other investigations – CXR, Montoux test –
f) Duration between diagnosis and start of treatment-
g) Treatment duration till now-
h) Any injections-

i) On what dates received treatment-
j) Follow up sputum-
k) Compliance-
l) Side effects- Jaundice/loss of appatite/red coloured urine/rash/
m) Weight before the start of treatment-
n) Present weight -
o) Previous treatment h/o for the same condition-No of times/Duration/Place-
6. Personal history:
a) Alcohol
b) Smoking/pan chewing/
c) Menstrual h/o(females)-
7. Social aspects:
a) House layout-
b) Method of disposal of sputum-
c) KABP assessment-
d) Under five child in the family-
e) Chemo prophylaxis for the under 6 child
8. Nutrition history
9. General physical examination:
Presence of BCG scar-
10. Examination of the lymph nodes:
a) Inspection
o Situation,Size of the swelling
o Shape
o Redness
o Skin over the swelling
o Sinus/fistula
b) Palpation
o Tenderness
o Rise in temperature
o Consistency
o Matting
c) Presence of other swelling in the body

11. Systemic examination:
12. Impression:

1 | Geriatric_Dr SSKAR_JIPMER
GERIATRIC
CHIEFCOMPLAINTS
• Locomotive–jointstiffness,pain,swelling,bonedeformity,limitedrangeofmovements
• Neurological–syncope,memoryloss,dizziness,falls,incoordination,paralysis
• CVS–dyspnoea,oedema,palpitations,Hypertension,Diabetes,Coronaryheartdisease
• RS–cough,sputum,haemoptysis
• Skin–itching,pigmentation
• GI–appetite,heartburns,constipation,diarrhea,dysphagia
• Psychiatry–Depression,sleepdisturbance
• Genitourinary–frequency,urgency,dribbling,forceof streamchanges,uterovaginalprolapse
• VisionandHearing–visualchanges,hearingloss,vertigo,tinnitus
DISABILITIES:(exploredifficultiesin vision,hearing,locomotion,useof publictransport)
SOCIALHISTORY:familysupport,instanceswherephysicalinabilitiesaffecttheirsociallife
FINANCIALSUPPORT:Benefitsreceived;Amountof moneyspenton healthcarepermonth
GERIATRICDEPRESSIONSCALE(SHORTVERSION)*
1) Areyoubasicallysatisfiedwith yourlife?YES/NO
2) Haveyoudroppedmanyofyouractivitiesand interests?YES/NO
3) Doyoufeelthatyour lifeisempty?YES/NO
4) Doyouoftengetbored?YES/NO
5) Areyou in goodspiritsmostof thetime? YES/NO
6) Areyouafraidthatsomethingbad is goingtohappento you?YES/NO
7) Doyoufeelhappymostof thetime?YES/NO
8) Doyouoftenfeelhelpless?YES/NO
9) Doyouprefertostayat home,ratherthangoingoutanddoingnewthings?YES /NO
10)Doyoufeelyouhavemoreproblemswithmemorythanmost?YES/NO
11)Doyouthink it iswonderfultobe alivenow?YES/NO
12)Doyoufeelprettyworthlessthewayyouarenow?YES/NO
13)Doyoufeelfullof energy?YES/NO
14)Doyoufeelthatyoursituationishopeless?YES/NO
15)Doyouthinkthatmostpeoplearebetteroff than youare?YES/NO
Answersinboldindicateprobabledepression.Althoughdifferingsensitivitiesand specificitieshave
beenobtainedacrossstudies,forclinicalpurposesscore> 5pointsis suggestiveof depressionand
shouldwarrantafollow-upinterview.Scores>10arealmostalwaysdepression.
*Kaplan&Sadock'ssynopsisofpsychiatryByBenjaminJ.Sadock,HaroldI.Kaplan,VirginiaA.Sadock

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