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cscs Under 5 child

Under 5 case study

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Krithik B Rajesh
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16 views

cscs Under 5 child

Under 5 case study

Uploaded by

Krithik B Rajesh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Clinico- Social Case Study

(Under 5 child)
IP/OP NO: DOA:
GENERAL INFORMATION

Name of the informant : Relation of informant to the child:

Name: Name of the Father:

Age: Sex: Religion:

Education: Father - Occupation: Father -


Mother - Mother -

Address:

Chief complaints: Complaints in chronological order of appearance (without details)

H/O presenting illness (chronological order):


Each complaint in detail in chronological order following SOCRATES
Additional positive and negative history that point towards a diagnosis

H/O past illness:


H/o Similar complaints in the past

H/o hospitalization

H/o any previous medical or surgical illness

H/o maternal malnutrition, anaemia or any significant medical/surgical condition during


antenatal period that could be relevant to this case..

Brief Natal and neonatal history


:
Growth and developmental milestones:

Immunization status (relevant):

Family history:

Treatment history: all treatment done for the current health condition before the child was
brought to our hospital
Personal history:
Appetite: Good/ Poor Diet: Vegetarian/ Mixed
Sleep: Normal/ Disturbed
Bowels: Regular/ Irregular

Personal Hygiene:-
Hair:

Teeth:

Bath:
Clothes:
Footwear:
Washing hands - before eating food/ feeding child:
after using toilet:

Nutritional assessment:
Food items Calories Proteins
Breakfast

Lunch

Snacks

Dinner

Total

Consumption coefficient:
RDA of calories:
Actual consumption:
RDA of proteins:
Actual consumption:
Comment on nutritional status : excess or deficit

Family composition:
Type of Family: Nuclear/Joint/Three generation

S.no Name Sex Age Relationship Education Income Occupation Health Immunization
To the status
patient
Total Family Income/Month:
Per Capita Income/Month:
Socio-Economic Status: As per BG Prasad’s scale -
Environmental assessment:
Housing: Own/Rented
Type of house: Kucha/ Pucca/ Semi pucca
Type of Floor:
Wall:
Roof:
No.of living rooms:
Doors:
Windows:
Ventilation:
Lighting
Kitchen:
Separate/Not separate
Type of fuel:

Water supply:
Source: Piped water/Bore well/Open well/Pond/Lake
Storage: Satisfactory/Unsatisfactory
Treatment: Boiling/Filtration /Chlorination/None
Latrine: Sanitary/In sanitary
Waste disposal:
Regularly collected/Irregularly collected
Safely disposed/Indiscriminate throwing
Occupational Animals: Present/ Absent
If present number:
Housed seperartely: Yes/No
Domestic Pets: Present/Absent
Nuisance vectors: Present/Absent
Vector breeding sites :

EXAMINATION:
General Examination:
Conscious/Unconscious
Well oriented/Not oriented
Pallor/Icterus/Cyanosis/Clubbing/ Edema/ Lymphadenopathy
JVP:

Temperature

Pulse:
Respiratory rate:
Blood Pressure:
Head to toe examination of child:-
Skin:

Hair:

Face:

Eyes:

Lips:

Tongue:

Teeth:

Gums:

Nails:

Rachitic changes:

Anthropometry: (first calculate age appropriate normal anthropometry measurements, then


record the child’s actual measurements and finally compare & comment)
Height:
Weight:
Mid Upper Arm Circumference:

Chest circumference:

Head circumference:

Upper segment : lower segment

Systemic Examination: (Inspection/Palpation/Percussion/Auscultation of one relevant


system in detail)
Respiratory system:

Cardiovascular system:

Per Abdomen:

Central Nervous System:


Provisional Diagnosis:
Laboratory Investigations (Already done/ Advised):

Clinical Diagnosis:

Cultural assessment:
Physical exercises:

Recreation:

Food fads:

Food taboos

Cooking Practices:

Storage of food:

Treatment behaviour:

Attitude of -
Pt towards his own illness: Positive/Negative
Family towards patient: Positive/Negative
Community: Positive/Negative
Effects of Patient’s illness on:
I. Family economy
II. :
III. Intra-familial relationship
IV. :
V. Social equilibrium
VI. :

Clinico Social Diagnosis:

Factors that made the patient come to the Hospital:

What levels of prevention have failed in this case?

What are the factors responsible for the disease / condition (Social, Economic, and
Family)?

What is the public health importance of this disease/ condition?


What are the Measures/ Advices to be given to prevent this disease / in this condition
and rehabilitation measures if any?

I. At Individual level
II. :
Medical:

Dietary:

Exercise:

Others:

III. At Family level :


IV.

V. At Community level :

Relevant National Health Programme:

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