Fever – Clinico-Social Case Proforma

IP/OP NO: DOA:

A. General Information / Identification data:

Name: Name of the Father/Husband:
Age: Sex: Religion:
Education: Occupation:
Address: (Complete Postal Address)
Family Composition:
Total no of members in the family: Type of family: Nuclear / Joint / 3 generation
No of Males = No of Females= No of Married couples =
No of dependants (Children less than 15 years and adults aged above 65 years) =
Name of Head of the family: Relation of HOF to given case:
SN Name Age Sex Relatio Educatio Occupatio Apparent health status
o n to n status n and immunization status
HOF

Total Family income: Rs. Per month/per annum/per week

Socio Economic Status: Calculate per capita monthly income (PCMI) of the family and
Determine the Social class to which the family belongs using Modified BG Prasad Scale
PCMI= (Total monthly family income ÷ Total no. of family members)
B. Complaints and History
Chief complaints:
 In chronological order
 In the patient’s own words, don’t use any medical terms
H/O Presenting Illness:
 Each symptom in detail using the mnemonic “SOCRATES”
S Site = location : Localised or diffuse
O Onset : when began, how long since, timing of day
C Character & Severity
R Radiation
A Aggravating & relieving factors: posture, breathing, medication, maneuvers
T Timing, Continuity, Progress
E Exacerbating factors & Associated symptoms (Risk factors of suspected
cause)
S Social Effects of the symptoms or illness
 Should contain both Positive and Negative complaints that are s/o of a differential
diagnosis or atleast the organ system that needs to be examined in detailed
 Ask for –
 Fever: onset, duration, grade, aggravating & relieving factors, association with
chills/rigors, appearance of rash, retro orbital pain, excessive sweating, pattern of
recurrence, association with headache, body pains (myalgias), delirium, treatment
received & its outcome
  Respiratory tract symptoms: H/o sore throat, nasal discharge, sneezing, Sinus pain &
heaviness in head, cough, expectoration, wheeze, SOB
 Genitourinary Symptoms: Frequency of micturition, dysuria, loin pain, and vaginal or
urethral discharge
 Abdominal symptoms: loose stools, with or without blood, Nausea & Vomiting, weight
loss and abdominal pain
 Skin Rash: onset, whether it started before or after onset of fever, appearance – macular,
papular, haemorrhagic, vesicular, nodular, erythematous, location, distribution, localized
or diffuse
 Joint symptoms: joint pain, swelling, limitation of movement, no. of joints involved,
location, continuity of pain – fleeting/ continuous
 Constitutional symptoms: Weakness, Fatigue, loss of appetite, lumps, night sweats,
sleeplessness
 H/o Insect/vector/rodent/animal bite
H/O Past Illness:
 Similar illness in the past – take details of when it occurred, whether diagnosed & treated
 Comorbidities – HIV, TB, DM, HTN, IHD, Asthma, Jaundice, Fits, Immune disorders: when
diagnosed, duration, current treatment & regularity of Rx, completion & outcome of
treatment (in case of past h/o TB)
 Risk factors – tattooing/ piercing, trauma/accident, blood transfusions, dental extraction,
circumcision
 H/o hospitalization, H/o Surgeries – time, place, what type of surgery, Ho minor operations
or procedures
 H/o Any Other medical conditions

Family history:
 Similar illness: in case of communicable diseases, genetic disease, cancer
 Relevant risk factors – Infections running in families like TB, leprosy, filariasis, cholera,
typhoid, etc
 Comorbidities

Treatment history:
 What all treatments the patient received for his ailment till before he was admitted in
our hospital:
 Name of the drug: Generic name of the drug
 Dose: gm/mg/mcg/IU, etc
 Route of administration: Oral/IV/IM/SC/PV, etc
 Schedule: OD/BID/TID/QID, etc
 Duration of the treatment: been taking it for how many days/months/years
 Continuity: Regular/irregular
 H/o using Vitamins/Traditional /Herbal medicine & alternative medicine such as
acupuncture
 Drug & allergy history – dosage, timing, since how long
 H/o taking Malaria Prophyllaxis
Personal history:
 Appetite: Good/ Poor
 Diet: Vegetarian/ Mixed
 H/o Consumption of unpasteurized milk or milk products
  Sleep: Normal/ Disturbed, Adequate/inadequate
 Bowels: Regular/ Irregular, any change in consistency, frequency
 Personal hygiene: Bathing, combing, clipping nails, handwash practices, daily change of
clothing, oral hygiene, habit of wearing footwear
 Addictions: tobacco (chewed/smoked/other forms), alcohol, others – duration, quantity,
type or form of substance, frequency
 Sexual behaviour: no. of partners, contraceptive usage, any other high risk behaviour
 H/o association with animals / birds in his/her house or occupationally- exposure to birds
or animals
Immunization status:
 Immunization against Hepatitis A &B, Typhoid fever

Social History/Contact History/ Travel History:

 H/o similar complaint in any person at home, workplace, neighborhood, educational
institution or place where frequently the patient visits
 H/o travel recently to any place – name of place, duration of stay

Diet history:
 Staple diet, quantity of fruits and vegetables consumed per day
 No of meals consumed per day, regular or irregular
 Whether consumes: refined carbohydrates, deep fried foods, processed and ready to eat
foods, bakery products, fatty foods, canned foods, preserved food with high salt content
 Major method of cooking followed: steaming, shallow fry, deep fry, baking
 Food fads, Food taboos
 Food storage practices
 Dietary Assessment:
 Step 1: Take 24 hour Dietary recall history of the patient. Calculate Actual Dietary
Intake of calories and proteins using diet history
 Step 2: Calculate Consumption Units (or) Assess Recommended Intake using
appropriate age, sex, body weight, physiological state, occupation/physical activity,
comorbidity
 Step 3: Comment on deficit or excess
Environment History:
Housing: Own/Rented Type of house: Kucha/ Pucca/ Semi pucca
Type of Floor: Wall: Roof:
No. of living rooms: Doors: Windows:
Ventilation: Assess using criteria for ventilation

Lighting: Natural/ Artificial, Adequate/Inadequate

Overcrowding: Present/ Absent. Assess using criteria for Overcrowding
Kitchen:
Separate/Not separate
Type of fuel used for cooking:
Water supply:
Source: Piped water/Bore well/Open well/Pond/Lake
Storage: Satisfactory/Unsatisfactory
Treatment: Boiling/Filtration /Chlorination/None
Latrine: Sanitary/Insanitary
Waste disposal:
 Regularly collected/Irregularly collected
Safely disposed/Indiscriminate throwing
Occupational Animals/Poultry: Present/ Absent
If present number:
Housed separately: Yes/No
Domestic Pets: Present/Absent
Nuisance vectors/Rodents: Present/Absent
Vector Breeding places: Present/Absent

C. PHYSICAL EXAMINATION
(i) General Examination:
 Build and Nourishment
 Consciousness and orientation to time, pace and person
 Anthropometry: Height: cms Weight: kg BMI:
o Waist circumference: cms Hip circumference: cms Waist – Hip
Ratio:
 Pallor/ Icterus/ Cyanosis/ Clubbing/ Koilonychia/ Pedal Edema/ Lymphadenopathy
 Skin: Hair: Any Gross abnormalities:
 Torniquet test
 Vital signs: (In detail citing posture, anatomical site where recorded, with proper
measurement units, regularity, character, any specific type, comment whether normal or
abnormal)
Temperature-
Pulse rate-
Respiratory rate-
Blood Pressure-
Oxygen saturation-
(ii) Systemic Examination:
 One system has to be examined in detail (Inspection, Palpation, Percussion, Auscultation
or any special examination as relevant) as per the major organ system involved based on
history taken. The system to be examined for each case are as follows.
 Respiratory system: ARI, TB, Fever with Respiratory symptoms
 Per Abdomen: Fever (when uncertain), Typhoid, Malaria, UTI
 Examination of Ulcer: Diabetic Foot, Leprosy ulcer
 Examination of Skin lesions, nerves, deformities: Leprosy
 Examination of lump: TB lymphadenitis, Lymphomas, Abscess
 Examination of CNS: JE, Cerebral malaria
 Examination of oral cavity & oropharynx: Tonsillitis, Pharyngitis
 Examination of Genitourinary tract: UTI, STD, Pelvic mass, Genitourinary discharge
 Other systems have to be examined and any abnormalities observed should be
noted or else comment on normal observations made.

D. KAP Assessment:
Assess :
  Knowledge regarding the condition of the patient : source, mode of transmission, its
manageability or curability, complications if not treated, change of social role of patient
due to his condition.
 Attitude of the patient towards his condition, his family, friend and relatives’ attitude
towards the patient and his special needs or interventions due to the disease condition
 Practises regarding preventive aspects followed by the patient and his family with
regards to the disease, treatment adherence and compliance
If possible, assess the availability of health facilities near their place of residence, knowledge
regarding them, attitude towards them and actual practise followed in their utilization

E. Summary:
• Should include identification data, chief complaints, positive and negative points in
history (do not forget social factors) that make diagnosis possible and confirmatory
examination findings

F. Clinico Social Diagnosis:

• Contains 3 parts:
1. Identification data
2. Clinical Diagnosis
3. Social Diagnosis
• Do not mention complaints here
• Make a diagnosis clinically and completely (including severity of disease condition and
complications)
• Social factors - most appropriate (at least 3) to the causation of the condition should be
given as social diagnosis
• Format for Clinico social diagnosis:
A year (age) old female/male (sex), belonging to Socioeconomic Class
I/II/III/IV/V as per B G Prasad’s classification (SE Status), hailing from a
nuclear/Joint/ 3 generation family (type of family), from a rural/urban area (place of
residence) is a case of (Primary Disease/condition
and clinical type) of Mild/Moderate/Severe/ controlled/Uncontrolled severity
(Degree of illness) with (Complications due to
Primary disease) with (1 or more comorbidities).
His/ Her condition is attributable to , ,
and (3 Social factors identified from the case history and examination)
Example:
A 26 year old female, Mrs X, belonging to Class 4 (Lower Middle Socioeconomic Class)
as per B G Prasad’s classification, hailing from a nuclear family is a case of
uncomplicated Dengue fever. She is classified as DF as per WHO classification.
Her condition is attributable to residing in endemic area, presence of vector breeding sites
in the peridomestic area and malnutrition.

G. Lab investigations:
 General investigations
 Specific and Confirmatory investigations
 Investigations to assess prognosis

H. Levels of Prevention failed in this case

 Determine the current mode of intervention recommended
  Assess which level this intervention falls under: Primordial/Primary/Secondary/Tertiary
 Comment that All the levels below the current level have failed

I. Measures/ Advices to be given to prevent this disease

I. At Individual level :
Medical:

Dietary:

Exercise:

Others:

II. At Family level :

III. At Community level :

Relevant National Health Programme:

Malaria, Filaria, Dengue, JE – National vector Borne Disease Control Program (NVBDCP)

TB – RNTCP/NTEP

Leprosy – NLEP

STDs/ HIV – NACP

Cancers/ Diabetes - NPCDCS