Essentials of Community Medicine Practicals DK Mahabalaraju
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1CLINICOSOCIAL CASE STUDY (Hospital)
 
  • 1. Model Proforma
  • 2. Mother and Child Health
    • • Antenatal Care
    • • Postnatal Care
    • • Undernutrition (PEM/Marasmus)
  • 3. Communicable Diseases
    • • Typhoid
    • • Diarrhea
    • • Hepatitis-A
    • • Tuberculosis
    • • Leprosy
    • • Hepatitis-B
    • • Sexually Transmitted Disease
    • • Dengue
    • • Malaria
    • • Fever (Pyrexia of Unknown Origin, PUO)
  • 4. Noncommunicable Diseases
    • • Diabetes Mellitus
    • • Hypertension
    • • Iron-deficiency Anemia
    • • Iodine-deficiency Disorders
    • • Obesity2

Model ProformaCHAPTER 1

This proforma can be used for all cases with relevant modifications.
 
PART I - GENERAL INFORMATION
Name and address of the patient:
Ward No:____________ Unit:__________
_______________________________________________
IP/OP No:______________________________________
_______________________________________________
Date of Admission:
_______________________________________________
Mode of Admission: Self/Referral
Telephone No:
 
INDIVIDUAL PROFILE
Age:
Education:
Sex:
Occupation:
Religion:
Income:
Caste:
Languages known:
Habitation: Urban/Rural/Urban slum
H/o Migration: Yes/No
Details (if migrated):
________________________________________________________________________________________
Blood group:
Drug sensitivity:
Seropositivity:
________________________________________________________________________________________
 
Marital Status
Married/Unmarried:
Number of living children: M_____, F_____
Immunization Status (if relevant)______________________
Important Health Events
4
Long hospital stay:
Regular medications with details:
Operations:
Addiction to drugs:
Blood transfusion:
Suicide attempt:
Chronic diseases/Health distortion:
Poisoning:
Injuries/Burns/Accidents:
Others:
 
Personal Hygiene
Clothes:
Oral hygiene:
Hair:
Nails:
Bath/Hand wash:
Footwear usage:
 
Lifestyle
Diet: Veg/Non-veg/Mixed
Food habit: Regular/Irregular
Physical activity:
Other habits: Alcohol/Smoking/Tobacco chewing
Sexuality (as relevant):
 
Social Relationship
  1. With family members
  2. With society
  3. Family members with patient
 
FAMILY PROFILE
 
Family Structure
Age (in completed years)
Number
Total
Male
Female
< 1 yr (Infants)
1–5 yr
6–15 yr
16–64 yr
> 65 yr
 
Family Composition
Family type: Nuclear/Joint/Three generation   Total members: ________
Sl No
Name
Age in years
Sex
Marital status
Education
Occupation
Income
Medicosocial status*
5
 
Socioeconomic Class_____________________
(According to modified BG Prasad classification)
 
*Medicosocial Status
Infant
Children under 5 year
Pregnancy
Lactation
Old age
Leprosy
HIV/STD
Cancer
Diabetes
BP/Cardiac problem
Disability
Mental retardation
Psychiatric problems
Alcohol addiction
Social evils
 
Living Conditions (Housing)
House is a dwelling structure used by man for settlement, which provides physical, mental and social health needs of an individual and of the family.
Sl No
Housing standards
Score: 1 for Satisfactory criteria 0 for Poor criteria
1.
Construction: Locality, Safety, Protection
2.
Space: Spatial sufficiency to prevent overcrowding
3.
Light and Ventilation
4.
Water: Adequacy, accessibility and safe storage of water
5.
Sanitation: Washing, bathing, toilet facilities, sanitary disposal of kitchen waste, garbage and excreta
6.
Kitchen: Facilities for hygienic cooking and storage of food, smoke outlet
7.
Environment Disturbances: Noise, air pollution, weather inclemency toxic fumes, dust, odor, moisture, open drain, etc. Vector like fly, mosquito, rodent and other nuisance.
8.
Animals: Pet, cattle, poultry keeping
9.
Cleanliness of persons and premises
10.
Connectivity: Road, transportation, communication, schools, hospital cultural, social, recreational, fire, police, etc.
Assessment of living condition: Score: 6–10 Satisfactory, 0–5 Poor
 
Vital Events in the Family
Birth:
Adoption:
Marriage/Divorce:
Death with cause:
 
Social Status of the Family
Education:
Occupation:
Living condition:
Social relationship:
Socioeconomic status:
6
 
Social condition assessment: Satisfactory/Poor
 
 
Nutritional Intake of the Family
Food items
Intake of the family (gm)
RDA for the family (gm)
Remarks/Inference
Cereals
Pulses
Green leafy vegetables
Roots and tubers
Other vegetables
Fruits
Oil
Sugar and Jaggery
Milk
Meat/Fish
 
Coefficient Unit (CU) required by the family:
 
 
Health Status of the Family (in brief)
Physical health:
Mental health:
Social health:
Spiritual health:
 
PART II - MEDICAL (CLINICAL) DETAILS OF THE PATIENT
 
History of Present Illness
Chief complaints (in chronological order)
Onset (sudden/gradual)
Duration
Description of symptoms
1.
2.
3.
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:
 
Past History (as relevant)
History of previous illness/hospitalization for similar complaint:
Time of illness:
Nature:
Hospitalization:
Complications:
Treatment:
Diet history (as relevant)
Epidemiological History For Communicable Diseases
Any similar case in the family: Yes/No
Any similar case in neighborhood: Yes/No
7Any contact with similar case: Yes/No
Existence of similar disease in the locality/district:
Other relevant information:
 
Family (Hereditary) History For Noncommunicable Diseases
Noncommunicable disease: Present/Absent
If yes, specify:
Genetic background of noncommunicable disease: Present/Absent
If yes, specify:
Degree of relationship:
Existence of similar disease in the locality:
 
General Examination
Built:
Anemia:
Height:
Clubbing:
Weight:
Cyanosis:
Nourishment:
Jaundice:
Temperature:
Lymphadenopathy:
Pulse:
Edema:
Blood pressure:
Respiration:
 
Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:
Epidemiological Diagnosis
 
Lab Investigations
Sl No
Examinations required
Report
1.
2.
3.
4.
Clinical Diagnosis
 
Criteria for
  1. Diagnosis:
  2. Classification:
8
 
MEDICOSOCIAL DISCUSSION
 
Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors
Host factors
Biological
Nutritional
Physical
Chemical
Mechanical
Others
Age
Sex
Ethnicity
Migration
Inheritance
Nutrition
Immunity
Others
Environmental factors
Social factors
(Physical, Biological, Psychosocial)
Poor housing
Lack of potable water supply
Improper sanitation
Flies and pests nuisance
Occupational environment
Stress
Economic conditions
Sociocultural practices/Superstitions
Prejudice/Taboos/Stigma
Religious practices
Lack of education
Unemployment
Incorrect knowledge, attitude and practice
Bad personal hygiene
Malnutrition
Habit and lifestyle
Non-availability and utilization of health services
 
Risk Factors for Noncommunicable Diseases (modifiable)
Smoking:
Alcohol:
Tobacco usage:
Obesity:
Lack of activity/Lifestyle:
Hormones:
Personality:
Use of oral pill:
Miscellaneous:
 
Levels of Prevention
Levels of prevention
Which level has failed?
How it could have been prevented?
Primary*
Health promotion
Specific protection
Secondary
Early detection and prompt treatment
Tertiary
Disability limitation
Rehabilitation
*In noncommunicable diseases, population strategy and high-risk strategy is established in primary prevention.
9
 
Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease
Particulars
Knowledge
Attitude (beliefs and customs)
Practice
Cause
Treatment
Prevention
Health services
Others
Influence of Medicosocial Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:
Medicosocial Diagnosis
 
MANAGEMENT
 
General and Specific Measures
Treatment Plan
  1. Case:
  2. Contact/Carrier (as relevant):
  3. Other Family Member (as relevant):
National Health Programme Regarding the Disease
Recent Advances/Modifications in Medicosocial Management of the Condition
 
ADVICE
 
(Preventive, Promotive and Curative)
 
 
Patient
 
 
Family
 
 
Community
 
 
Review Questions
✓ Comment on the model proforma
✓ What have you understood regarding?
Epidemiological diagnosis
Clinical diagnosis
Medicosocial diagnosis