Clinico-social-case format (Index case- ANC/ PNC)

1. Identification & demographic details:

Name: 

Age: 

Sex: 

Marital status: 

Husband's name:

Blood group & Rh type:

Gravida____Para_____Living____Abortions____ 

MTP: Yes_____/ No

Religion and caste:

Education: 

Occupation:

Address: 

Nearest health facility: 

Place opted for delivery: Home/ Hospital/ Not decided

(If admitted in hospital)

Ward/ Unit/ Treating doctor:________________________

Date of admission:____/______/____

IP/OP No:_______

Mode of admission: Self/ Referral

2. Presenting/ Chief complaints:

Complaints of____________since______days/ months/ years. (In chronological order)

3. History of presenting illness:

My patient was apparently alright then he developed _____________(name of the symptom) which was insidious/ sudden in onset, progressive/ non-progressive in nature. (describe each symptom in detail with treatment history if taken). There is no history of _______________________. (Ask & write the negative history based on probable causes.)

4. Past history: 

Write down if any history of past surgeries, illnesses, blood transfusions, allergies, or trauma.

H/O Fever with rash: Yes/ No

TORCH infections: Yes_____/ No

HIV/ STD: Yes/ No

Diabetes/ Hypertension: Yes_____ since____years/ No

Any h/o drug reactions: Yes/ No

5.Menstrual history: 

Age of menarche___________years

Menstrual cycle: Regular/ irregular

Passing clots: Yes/ No

Used____Pads/ day

6. Obstetric history:

G___P___L_____A

Age of marriage:_____________Years

Type of marriage: Consanguinous/ Non-consanguinous

Duration of active married life:__________Months/ Years

Interval between previous & present pregnancy:_____months/ years

LMP:_______/________/________

EDD_______/_________/________

POG (Period of gestation):_____________Months

Sexually active up to:________Months POG

Registration of pregnancy done at:_______________

(Name of place & date)

History of present pregnancy:

Antenatal care:

1. Time of registration________(in months)

2. Confirmation of pregnancy: UPT at home/ a health center/ other

3. Source of Antenatal care__________

4. No.of Home visits___________

5. Antenatal period____________

First trimester:

• Registration details_____________
• Excessive vomiting: Yes/ No 
• Bleeding p/v: Yes/ No  
• Fever with rashes: Yes/ No 
• Drug intake: Yes_______________________/ No
• Weight gain: __________Kg
• Investigations-Hb%, CBC, Urine routine & microscopy, USG , blood grouping & Rh typing, VDRL, HBsAg, HIV, RBS, TFT, LFT, etc.
• Folate supplementation: Yes since______/ No
• TT: Taken/ Not taken/ 1st dose/ Both doses

Second trimester:

• Quickening: Felt at_________ weeks/ Not felt
• Weight gain: Yes__________Kg/ No
• Blurring of vision: Yes/ No 
• Epigastric pain: Yes/ No 
• Pedal edema: Yes/ No 
• Headache: Yes/ No 
• Iron and calcium supplementation: Taking daily OD/ BD/ No
• Side effects because of IFA supplementation: Yes Nausea/  vomiting/ loss of appetite/ change in the colour of stools/ No
• Hours of sleep/rest: Afternoon___hours and night___hours
• Tetanus toxoid immunization: Yes 1st dose/ 2nd dose/ No
• Investigations: Hb%, CBC, Urine routine & microscopy, Blood suger-FBS & PPBS, USG Abdomen, LFT, KFT, TFT, etc.

Third trimester:

ANC visits: Yes ______times/ No

Weight gain: Yes_____Kg/ No

Warning signs: Present/ Absent

• Pain abdomen: Yes/ No
• Decreased perception of fetal movements: Yes/ No
• Leaking / Bleeding pv: Yes/ No
• Any high risk status: Yes_____________/ No

Intranatal care:

Date of delivery/ abortion/ MTP: _____/_____/______

Place of delivery/ MTP: Home/ institutional (HSC/ PHC

/ CHC/ Private)

Typeof delivery: Vaginal/ C-section/ Instrumental 

Any complications: Yes/ No

Attended by:________________ 

No.of days of hospitalization:______

Outcome of Pregnancy: Spontaneous Abortion/ MTP/ Stillborn/ Livebirth

Baby details:

Sex: Male/ Female/ Third gender

Weight: ____________Kg

Length:___________cm

Cried at birth: Yes/ No

Birth injury: Yes/ No

Congenital defects: Yes/ No

Postnatal care:

Home visits during the postnatal period: Yes_____times/ No

Post obstetric history:

Family planning:

• Do the couple know that it is possible to prevent or postpone pregnancy: Husband: Yes/ No; Wife: Yes/ No 
• Are they aware of any methods of  preventing or postponing pregnancy: Husband: Yes/ No; Wife: Yes/ No
• If yes, which method(s):_____________________
• Attitude towards family planning: Husband Willing: Yes/ No;
• Wife Willing: Yes/ No
• Are they practicing any method: Yes/ No
• If yes, which method:__________
• If no, did they ever practice: Yes_________/ No
• Describe how they decided on a particular method and reason for changing if any___________
• Are they satisfied with the method used: Yes/ No
• If no, give reasons:_________

Sexually Transmitted Infections:

Condition:________________

Received treatment for STI - Yes/ No

Place of treatment - Public/ Private hospital

Husband treated - Yes/ No

7. Personal history:

Diet: Veg/ Mixed/ Vegan

Appetite: Normal/ Increased/ Decreased

Bowel & bladder: Regular/ Irregular

Sleep: Normal/ Increased/ Decreased

Physical activity: Sedentary/ Moderate/ Heavy worker

Duration of work:________hours

Addiction: Yes/ No

(If yes, then specify Gutkha/ Pan-mashala/ Tobacco chewing/ Smoking/ Alcohol/ IV drugs)

8. Family history: 

Family type: Nuclear/ Joint/ 3 generation

Family composition (draw a family tree)

Any history of consanguinity: Yes/ No

Family relationships: Good/ Not good

The response of family towards the illness:_____________

(No need to write if it is included in the family details)

9. Environmental history:

Housing:

Toilet:

Waste disposal:

Drinking water:

Animals/ pets:

Occupational environment:

(No need to write if it is included in the family details)

10. Socio-economic history:

Interaction with society: Yes/ No

The response of society towards the person: Good/ Bad/____ 

Presence of stigma: Yes/ No

if yes specify____________________

Participation in festivals, marriages and other social activities & involvement in social groups: Yes/ No

Total family income:______________

Expenditure on diet and medical care:__________

Savings or debts_____________________

Family tensions due to the economic situation: Yes/ No

(No need to write if it is included in the family details)

Social welfare measures:

PDS/ JSY/ Anganwadi/ others__________

11. Nutritional history (as relevant to the case):

Calculation of calories, carbohydrates, proteins & fats (& salts) being supplied to the person by 24-hour diet recall method (tabular format for breakfast, lunch, evening snacks & dinner) and required amount by the person through diet. Mention the deficiency or excess.

(No need to write if it is included in the family details)

12. Psychosocial history:

Mental changes: Memory loss/ Depression/ Any other______

Living with: Spouse/ Son/ Daughter/ Relative/ Others

Emotional disorders: Loneliness/ Feeling unwanted/ Insecurity/ Other________

13. General physical examination:

Vitals:

Blood pressure (BP): ___________ mm Hg Right/ Left arm sitting/ supine position.

Pulse rate(PR): __________ beats/ min regular/ irregular

Respiratory rate (RR): __________ cycles/ min

Temperature: ___________ degree F

Pallor: Yes/ No

Icterus: Yes/ No

Clubbing: Yes/ No

Cyanosis: Yes/ No

Lymphadenopathy: Yes/ No

Edema: Yes/ No

Anthropometry: 

Built: 

Nourishment:

Height: _________m

Weight: ________kg

BMI:__________ kg/ m2

Head to toe examination:

General cleanliness: Good/ Bad

Hair: clean/Unclean/ Combed/ Uncombed

Eye: Vision: Normal/ Decreased; Using spectacles: Yes/ No; Senile cataract: Yes/ No/ Mature/ Imature; Glaucoma: Yes/ No; Operated: Yes/ No

Ear: Hearing: Normal/ Decreased; if decreased ,type of hearing loss: Conductive/ SNHL/ Mixed; Ear discharge: Yes/ No

Oral: No of teeth:______; Using dentures: Yes/ No; Oral hygiene: Good/ Poor

Thyroid swelling: Yes/ No

Breats: Normal/ Abnormal________

Any other significant finding____________________

14. Systemic examination:

Obstetric Examination:

Inspection:

Linea nigra: Present/ Absent

Striae gravidarum: Present/ Absent

Any scar: Present/ Absent

Prominent veins: Present/ Absent

Palpation:

Abdominal girth:____cm

Fundal grip:____________________________

Lateral grip:_____________________________

1st Pelvic grip:____________________________

2nd Pelwic grip:___________________________

Auscultation:

Fetal heart sound:_____beats/min

Important clinical findings:

1.

2.

Respiratory system:

Inspection:

Palpation:

Percussion:

Auscultation: 

Cardiovascular system:

Inspection:

Palpation:

Auscultation: 

Gastrointestinal system:

Inspection:

Palpation:

Percussion:

Auscultation: 

CNS examination:

Inspection:

Palpation:

Musculoskeletal system: 

Inspection:

Palpation:

Provisional clinical diagnosis:

15. Laboratory investigations:

Hb%, CBC, Urine routine & microscopy, Urine albumin, USG, Viral markers, Blood grouping & Rh typing, KFT, LFT, TFT, Blood sugar-FBS, PPBS, Pap smear test, etc.

(already done and planned in future)

Summary:

Mrs. X, -------year-old, married since------------, is currently in 1st/ 2nd/ 3rdpregnancy in ------months of gestation with ------ such complaints (high risk or not) is planning for safe confinement in ______ center.

Positive and Negative Factors:________

Level of failures:________

16. Comprehensive Diagnosis/ Clinico-social diagnosis:

This is the family of Mr.____________residing in ________ (name of the area), having______membered, nuclear/ 3-generation/ joint family,  belonging to socioeconomic status class __________ according to _____________ (name of the classification), a BPL/ APL card holder. The health problems, health demands & health needs of the family are _______________________. (Disease with/without complication, Social problem, Mental problems). The vulnerable individuals identified in the family are ________ (why are they vulnerable?)

17.Comprehensive management plan:

Advice to mother:

Health promotion: Diet, self-care, personal hygiene, mental preparation, child care, breastfeeding, use of Anganwadi & social benefits, etc.

Specific protection: TT & IFA

Early diagnosis: Warning signs/ Any other unusual symptoms