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CLINICO Socio Case Format - DM, HTN

The document outlines a comprehensive clinico-social case format for patient assessment, including personal, family, and environmental histories, as well as clinical examination details. It emphasizes the importance of various factors such as dietary habits, socio-economic status, and community diagnosis in understanding the patient's health. The format also includes sections for provisional diagnosis, management, and health education for the individual and family.

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6 views

CLINICO Socio Case Format - DM, HTN

The document outlines a comprehensive clinico-social case format for patient assessment, including personal, family, and environmental histories, as well as clinical examination details. It emphasizes the importance of various factors such as dietary habits, socio-economic status, and community diagnosis in understanding the patient's health. The format also includes sections for provisional diagnosis, management, and health education for the individual and family.

Uploaded by

t8ttm4qk4s
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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CLINICO-SOCIAL CASE

Clinico-social case format

Name

Age

Gender

Occupation (type of job and nature of job) – (nature of job – sedentary/moderate/heavy)

Religion

Education

Complete residential address (door number, street, locality, area) – (To assess on certain

epidemiological factors like epidemic/endemic nature, geographic trends, follow up)

Chief presenting complaints

(May be one or two complaints that made the patient to come to the hospital)

(Present it in chronological order)

H/O presenting illness

Elaborate the chief complaints (duration, mode of onset, severity, aggravating and relieving

factors)

Associated symptoms (related to the system involved) – Cardinal symptoms of the particular

system involved

Past History

H/O Tuberculosis, SHT, DM, Chronic medical illness, any other illness (duration, treatment for the

illness, complications due to the illness)

Personal history
Dietary habits (vegetarian/non vegetarian)

Smoking (duration, age started smoking, type [cigar/beedi/any other], frequency [number] per day, any

withdrawal symptoms

Alcoholism (duration, age started, type of alcohol, frequency and quantity per drink, any withdrawal

symptoms]

H/O of any drug abuse: (name of the drug, frequency of use, any withdrawal symptoms)

Bowel/bladder habit

Sleep-wake cycle

Family history (include everyone in the family)

SNo Name of the Relationship Education Occupation Income H/O


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)

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)

Environmental 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

Other important histories

Immunization History (Under-five case presentation)

Developmental history: (Under-five with MR/Hypothyroidism/Severe Malnutrition etc)

Drug history/Treatment history: (Drug intake, duration, frequency per day, dose if the patient knows

etc)

Menstrual History: (Antenatal /PNC /Adolescent girl with Anemia) – age at menarche / menopause;

duration of cycles and regularity; no. of days of flow and quantity; menstrual hygiene

Marital history: (Antenatal /PNC)

Dietary history for infant case: when breast feeding was started after delivery, pre lacteal feeds,

colostrum, exclusive BF, weaning.

GENERAL EXAMINATION

Built, nourishment, consciousness, orientation,

Pallor, icterus, cyanosis, clubbing, pedal edema, lymph-adenopathy (PICCLE)

Anthropometric measurements: height and weight (BMI)

HC, CC, MUAC (U5 case)

VITAL SIGNS: pulse, blood pressure (three measurements with 5 minutes interval), Respiratory rate,

temp

CLINICAL EXAMINATION: System examination (CVS, RS, PER abdomen, CNS)


Evaluation of hydration status: ADD case

Breast and thyroid examination: ANC/PNC

PROVISIONAL DIAGNOSIS (INDIVIDUAL-– ABOUT THE DISEASE IN THE INDIVIDUAL)

age, gender, diagnosis with/without complications

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

FAMILIAL, ECONOMIC, ENVIRONMENTAL FACTORS)

WHICH LEVEL OF PREVENTION IS FAILED?

MANAGEMENT

INVESTIGATIONS

TREATMENT

HEALTH EDUCATION- INDIVIDUAL AND FAMILY

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