CLINICO-SOCIAL CASE- Under 5 yerars

Clinico-social case format

Introduction:

 Name
 Age
 Sex
 Religion
 Education

Complete residential address (door number, street, locality, area) – (To assess on certain
epidemiological factors like epidemic/endemic nature, geographic trends, follow up)

Family history (include everyone in the family)

Name of the Relationship Education Occupation Income H/O
SNo family member to HOF similar
(patient) illness in
the
family/
health
status

1.

PEDIGREE CHART:

Type of family: Nuclear / Joint family/ 3 generation family

Any problems in the family (problem family, broken family, pathological family)

Total income of the family and Per-capita income

Socio economic status: (Using modified kuppuswamy classification/BG Prasad classification)

Chief presenting complaints

 Informant: mother/guardian
 Reliability of informant: good/fair
 Failure to gain weight/weak child
 Any other complaints & duration of all the complaints

H/O presenting illness

 Elaborate the complaints

 Failure to gain weight since ____ age. Weak as compared to other children in that age
group
 Not interested in games/apathetic
 History of appetite loss or normal
 History of pica
 History of weakness/tiredness/early fatigue
 History of passing worms per stool
 History of Acute Respiratory Infection (ARI) (cough & cold), diarrhea, fever with
chills & rashes (measles), hospitalization for any reason
 History of skin infection
 History of pus discharge from ear
 History of cough or expectoration for >1 month
 History of current loose stools
 History of infective focus like abscess & impetigo
 History of food intolerance (diarrhea after specific food)
 Bowel & bladder habits
 Activity level of the child (playful, active, not interested)

Past History:

 History of chronic cough (Tuberculosis), malaria, measles

 History of congenital heart disease
 History of any surgery
 History of any hospitalization
 History of ARI & diarrhea episodes in the last one year (5 episodes of ARI & 3
episodes of diarrhea per year are normal)
 Treatment given at that time & whether the child recovered without any complications

Antenatal History:

 Spontaneously conceived? Yes/No

 Spacing between pregnancies
 Birth order
  Early registration
 Any illness to the mother (drug intake, rashes, radiation exposure, jaundice &
hospitalization)
 Number of Antenatal Care (ANC) visits
 Tetanus Toxoid (TT), Iron and Folic Acid (IFA) & calcium received or not, if yes –
how many tablets, if no – reason for non-intake
 Total weight gain in the pregnancy
 Any Ultrasound Sonography (USG) done, any finding suggestive of Intrauterine
Growth Retardation (IUGR), placental insufficiency or any abnormality
 Diet intake was increased in pregnancy or not
 Any treatment received
 Rule out hyperemesis, pre-eclampsia, eclampsia, infections, antepartum hemorrhage,
anemia, etc.
 Hemoglobin (Hb) level of the mother, blood group of the mother (if possible)
 General overall health of the mother

Natal History:

 Term/preterm
 Hospital delivery/Home delivery?
 Mode of delivery? Normal/Lower Segment Cesarean Section (LSCS)/difficult labor
 Complication at birth (if possible, ask for APGAR)
 Cried immediately after birth or not
 Birth weight?
 Any hospitalization at birth or anomaly?

Postnatal Period:

 When was feeding started, was there any problem in feeding?

 Any disease or hospitalization after birth?

Feeding Practice:

 Was any prelacteal feed given?

 Was colostrum given?
 Was exclusive breastfeeding practiced? Till what age & if it's not practiced, what was
the reason?
 When was weaning started?
 Any history of bottle feeding?
 Foods from Anganwadi used or not (elicit the reason if not availing services from
Anganwadi)

Breastfeeding:

 Number of feeds given per day/night, elicit the history of night feeds? Whether
 feeding on demand?
 Any breast problem
 Total duration of breastfeeding?
 Any commercial formula feeds given?
 If animal milk was given, was it diluted?

Immunization History:

 Bacillus Calmette–Guérin (BCG) scar? Yes/no (only if the child is more than 2
months as BCG scar develops in 6 weeks)
 Oral Polio Vaccine (OPV)/Hepatitis B: 0 dose
 OPV/Diphtheria, Pertussis, and Tetanus (DPT)/Hepatitis B: 1, 2, 3
 Measles & Measles, Mumps, and Rubella (MMR): given on __
 OPV & DPT booster I & II
 Typhoid
 Vitamin A: last dose
 Verify immunization card or elicit history (ask mother if any vaccine was being given
based on the schedule of vaccination)
 Any other vaccine given
 Pulse Polio rounds given
 Is there any delay? Reason for that
 Any adverse reaction to any immunization
 Next vaccine is due on __

Development History:

 Whether milestones achieved for present age?

 Whether any delay in the pattern of achievement?
 Gross motor
 Fine motor
 Social
 Language

Treatment & Investigation History:

 Treatment so far taken

 Doctors visited – Informal care providers/AYUSH/Registered practitioners/Public
sector hospitals (reasons for preference to visit a particular practitioner)
 Response to treatment
 Satisfaction with treatment given
 Investigations done: __
 Deworming done: Yes/No
 Family history of similar illness in other children of the family
 History of Tuberculosis or any chronic illness in family members
Diet History: by 24-hour recall method

Dietary history:

Use 24 hours recall method – Ask the patient regarding his diet consumed the day before and the diet
should be converted into calories.

Compare it with the reference standard. (RDA – for that particular age group, using the Indian
reference men / women criteria

Comment on the calories (excess/deficit)

Environment history:

Type of house (Pucca/Semi pucca/Kutcha)

Situation/location:

Set back (present / absent)

Floor, roof, walls, windows, number of rooms:

Ventilation: adequate/inadequate

Lighting: adequate/inadequate

Separate kitchen: yes/no (method of storage of food materials). Fuel used, exhaust+/-, garbage disposal

Separate store room: Storage of raw materials

Separate toilet:

Habit of Open air defecation:

Overcrowding: (define according to number rooms per person, space availability/sex separation)

Solid waste: storage, transport, disposal (frequency of disposal from the house)

Water: Source, storage, palatability, color, odor, whether the water is disinfected or not. water used
for cooking purpose

Peri-domestic sanitation: Fly breeding and mosquito breeding source

H/O pet animals: If yes detailed history of the premises of the animals reared. Immunization history of
the animals, cleaning of the animals, animal excreta disposal

Pest/rodent menace +/-

Socio cultural history: (Pertaining to the case)

Knowledge

Attitude

Practice

Local cultural habits/beliefs/customs

GENERAL EXAMINATION:

Conscious & oriented-

Afebril-

Pallor Icterus- Present/absent

Cyanosis - Present/absent

Clubbing - Present/absent

Pedal oedema- Present/absent

Lymhadenopathy - Present/absent

PR-

RR -
Anthropometry: :
Normal Inference
Measurement Value

Height
Weight
Head Circumference

Chest Circumference

Mid Arm Circumference

Systemic examination

Finding
System Examination
Cardiovascular System
(CVS)
Respiratory System (RS)
Central Nervous System
(CNS)
Abdomen

PROVISIONAL DIAGNOSIS:

COMMUNITY DIAGNOSIS - INCLUDE THE FACTORS LIKE (SOCIAL, CULTURAL,

FAMILIAL, ECONOMIC, ENVIRONMENTAL FACTORS)

MANAGEMENT

INVESTIGATIONS

TREATMENT

HEALTH EDUCATION-
To the mother:

To the family:

To the community:

PROGRAMMES: 1. Integrated Child Development Services (ICDS) Scheme:

 Provides supplementary nutrition, non-formal pre-school education, health care,

immunization, health check-ups and referral services through Anganwadi Centers.

2. National Nutrition Mission (POSHAN Abhiyaan):

 Aims to reduce stunting, underweight, anemia and low birth weight through
interventions across nutrition cycle.
 Focuses on adolescent girls, pregnant women, lactating mothers and children under 6
years.

3. Janani Suraksha Yojana (JSY):

 Promotes institutional delivery by providing cash assistance to pregnant women.

4. Janani Shishu Suraksha Karyakram (JSSK):

 Provides free and cashless services to pregnant women and sick infants up to 1 year of
age in government hospitals.

5. Universal Immunization Programme (UIP):

 Provides free vaccines against 12 vaccine-preventable diseases for children.

6. Vitamin A Supplementation Programme:

 Provides vitamin A solution to children aged 9-59 months to prevent night blindness.

7. Iron and Folic Acid Supplementation Programme:

 Supplies iron and folic acid tablets to pregnant and lactating women to prevent
anemia.

8. Rashtriya Bal Swasthya Karyakram (RBSK):

 Provides comprehensive care by screening for defects at birth, diseases, deficiencies

 and development delays in children 0-18 years.

9. MAA - Mothers' Absolute Affection Programme:

 Promotes breastfeeding through awareness generation and skilled counseling services.

10. PMMVY - Pradhan Mantri Matru Vandana Yojana:

 Provides cash incentives for improved nutrition for pregnant and lactating mothers.