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UG_Clinico Social Case Format_VMMC Final-1

The document outlines a comprehensive clinico-social case format for patient assessment, including sections on general information, clinical history, healthcare delivery, nutritional status, socio-demographic factors, environmental conditions, and knowledge attitudes. It emphasizes the importance of detailed examinations and assessments to formulate a provisional diagnosis and management plan. The format also includes sections for preventive measures and community-level interventions to enhance patient care.

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subhikshasenthamil
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12 views

UG_Clinico Social Case Format_VMMC Final-1

The document outlines a comprehensive clinico-social case format for patient assessment, including sections on general information, clinical history, healthcare delivery, nutritional status, socio-demographic factors, environmental conditions, and knowledge attitudes. It emphasizes the importance of detailed examinations and assessments to formulate a provisional diagnosis and management plan. The format also includes sections for preventive measures and community-level interventions to enhance patient care.

Uploaded by

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

Name of the student: Date:


A. General Information
Name of the Patient: Age/Sex: Informant:
Religion: Education: Occupation:
Address: Urban/Rural:
B. History:
I. Clinical assessment for pathology estimation
i. Chief Complaints
ii. History of presenting illness
iii. ANC/PNC/U5 child- GPLA score/ Obstetric history- present & past/ birth history/
immunization/ mile stone [U5child] should be elucidated
iv. Past history
v. Contact History( for all communicable diseases)
vi. Treatment history
vii. Family history
viii. Personal History

II. Health care delivery assessment


Nearest health facility: Sub centre:………… Kms……..
PHC/CHC/GH/GP/Private hospital: Kms……..
What you did after 1st symptom appears? ……………………. (Self Medication/Home
treatment/ Hospital-Private/Government/ over the counter/others) [Probe Reasons]

III. Nutritional assessment


Diet history: 24 hour recall dietary method

Duration Food item Calorie Protein


Morning
Afternoon
Evening

Night
Total
Required Calorie
Required Protein
Calorie deficit = [calorie required - calorie intake]/ Required calorie *100= ……%
Protein deficit = [protein required - protein intake]/ Required protein *100= ……%
Modification in diet:…………… (Chronic disease is must)

IV. Socio – demographic assessment


Type of family: Nuclear/ Joint/ Three generation
Family tree:

Family Composition:

Age/ Relation Marital


Name Education occupation Income Health status
Sex to head status

Other sources of income: …………….. (House rent/ cattle etc)


Economic status:
Per-capita Income: (Total family income/ total family members)
Socio-economic status: ……………….. (as per modified BG Prasad classification)
Vital events in the family {Past 1 years}- Birth / Death

V. Environmental assessment
House:
Type of House? (Pucca /Semi-pucca/Kutcha)
No of rooms and windows? ‘……………………. (Comment on Over crowding)
Ventilation & Lighting: (Comment- adequate/ inadequate)
Are the windows present on opposite sides of the other windows/ ventilators/doors?
Are there exhaust fan(s) in the patient’s house?
Artificial lighting/ natural lighting
Water supply:
Source of water………………….. Distance?.............
Quality of water Adequacy of water
Type of water storage Do you boil your water?
Does the water smell of chlorine? If yes, how frequently?

Refuse disposal:
Household waste: (Collection- method, frequency/ disposal- site, distance)
Kitchen waste: (Collection- method, frequency / disposal- site, distance)
Are there any drains in around the patient’s house? If yes, whether they are flowing or stagnated?
Toilet facility in the house?........ If no, Specify the type of defecation?
Are there any vectors/ rodents present inside the house?
VI. Knowledge, Attitude and Practice assessment

C. General Examination: PICCLE / Vitals / head to toe examination (U5 child)


D. Anthropometry measurements – [Height/ weight/ BMI/ for Child <2 years- Head Circumference/Chest
Circumference/ <5 years – Mid Arm Circumference]
E. Systemic Examination: [CVS/RS/CNS/Abdomen] – Inspection, Palpation, Percussion &Auscultation

F. Clinico Social Diagnosis (Provisional Diagnosis)


G. Investigations

H. Prevention assessment
Specific factors failed
Type of prevention Modes of intervention Failed/not failed
(Example)
Health promotion Air pollution
Primary
Specific protection Immunization
Early detection Delayed health seeking
Secondary
Prompt treatment Delayed treatment
Disability limitation Complications
Tertiary
Rehabilitation failure Permanent damage
I. Management:
Individual Level:
Medication: Drug compliance/ Adherence to treatment/ change after physician consultation
Regular & Complication check-ups:
Dietary advice:
Awareness on disease & Side effects:
Life style modifications:
Personal hygiene:
General advice: (other positive findings from the history)
Family Level: Community Level:
High risk screening: Programmes
Life style modification: - Specific for the disease
Diet advice: - Nutrition
Personal hygiene: - Sanitation
Sanitation: - screening
General advice:
Support to the patients:

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