Clinico-social-case format (Index case- Under five)

1. Identification & demographic details:

Name: 

Age: 

Sex: 

Religion and caste:

Education: 

Informant:

Reliability:

Address: 

Nearest health facility: 

(Ward no:____, Unit:___, IP/OP No:______, Mode of admission: Self/ Referral; if in hospital)

2. Presenting/ Chief complaints:

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

(Main complaints are Failure to gain weight, Fever, Cough, Respiratory difficulty, Diarrhea, symptoms suggestive of measles, Presence of danger signs like convulsions, loss of consciousness, inability to feed, distress, distended abdomen, Excess cry, irritability, etc.)

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.)

(Ask about h/o

• Recurrent infections (respiratory and skin to be especially enquired)
• Worm infestation
• Decreased appetite
• Chronic conditions especially TB
• Ear discharge)

4. Past history: 

Write down if any history of past surgeries, illnesses, blood transfusions, allergies, or trauma, treatment history (undergoing any treatment for a chronic condition, for the present condition, h/o treatment in the past)

(Hospitalisation, Measles, Chickenpox, ARI/Diarrhea)

5. Birth history: 

• Term/ preterm
• Normal/assisted/CS
• Birth weight:_______kg
• Incubator/ NICU care: Yes/ No
• Pre Lacteal feeds: Yes__________________/No
• Time of initiation of breastfeeding:_____
• EBF till what age:________
• Time of start of complimentary food:_________ 
• Nature of complementary food:_____________
• H/o use of artificial feeds

6. Antenatal, natal, and Postnatal history:

Trimester-wise history 1st, 2nd, and 3rd. Weight gain during pregnancy increased food intake during the pregnancy.

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

(Complications during pregnancy like

• Hyperemesis
• Pre-eclampsia
• Eclampsia
• Infections
• Preterm delivery
• Antepartum hemorrhage

Investigations did during pregnancy:

• Hemoglobin estimation
• Blood grouping,
• Ultrasound scanning.)

7. Developmental history:

Gross motor: As per age/ Delayed/ _____________

Fine motor: As per age/ Delayed/  ______________

Language:As per age/ Delayed/  _______________

Personal social: As per age/ Delayed/ ___________

8. Immunization history: 

• Vaccines are given appropriate for age: Yes/ No 
• BCG scar: Present/ Absent
• (reports of immunization like immunization card to be seen)
• Ascertaining whether measles vaccine and vitamin A was given: Yes/ No 
• Delay in immunization: Yes/ No
• If yes, the reason for the delay:________
• the optional vaccines administered:____________

9. Personal history:

Diet: Veg/ Mixed/ Vegan

Appetite: Normal/ Increased/ Decreased

Bowel & bladder: Regular/ Irregular

Sleep: Normal/ Increased/ Decreased

10. 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:_____________

h/o chronic condition in the family especially tuberculosis, 

h/o Similar case in other children of the family/ Locality/ District: Yes/ No 

h/o contraception usage by the couple.

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

11. Environmental history:

Housing:

Toilet:

Waste disposal:

Drinking water:

Animals/ pets:

Occupational environment:

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

12. 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)

13. 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.

(Anganwadi services utilization: Yes/ No)

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

14. Psychosocial history:

Mental changes: Memory loss/ Depression/ Any other______

Living with: Parents/ Grand-parents/ Relatives/ Shelter home/ Others

15. General physical examination:

Vitals:

Blood pressure (BP): ___________ mm Hg, 

Pulse rate(PR): __________ beats/ min

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: Normal/ Short

Nourishment: Normal/ Thin/ ____

Height/ Length: _________m

Weight: ________kg

BMI:__________ kg/ m2

Head to toe examination:

(Head to toe examination to look for evidence of PEM likefontanneles, eye changes, skin infections, dermatosis, hair changes, nail changes, signs of rickets like potbelly, wrist widening, richitic rosary, harrisons sulcus, bow legs, knock knees. Oral cavity examination for dental hygiene and assessing dentition.

Also, keep in mind the IMNCI format.) 

General cleanliness: Good/ Bad

Hair: Clean/Unclean/ Combed/ Uncombed/ Lusterless/ Depigmented/ Sparse/ Easily pluckable/ Flag sign

Face: Moon face/ Hallowing of cheeks/ Pointed chin/ Prominent bones/ Depigmentation/ Seborrhea around the nose

Eye: Vision: Normal/ Decreased; Conjunctiva: Normal/ Bitot's spots/Dry/ Sunken; Using spectacles: Yes/ No; 

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

Lips: Normal/ Cheilosis/ Angular stomatitis

Oral: No of teeth:______

Oral hygiene: Good/ Poor

Tongue: Pale/ Red magenta

Nails: Normal/ Pale/ Koilonychia/ ___________

Skin: Wrinkled/ peeling skin/ Flaky paint like patches

Subcutaneous tissue: Maintained/ Emaciated

Muscles: Normal/ Wasting

Chest: Prominence  of ribs

Abdomen: Distended/ Flat emaciated/ Ascites/ Enlarged liver

Leg: Edema on dorsum of feet & leg

Hips: Normal/ Loss of shape due to loss of fats

Alertness: Dull/ Disinterested/ Stays in same position for long time/ Irritable/ Crying excessively fretful

Any other significant finding____________________

13. Systemic examination:

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:

Laboratory investigations:

Hb%; Peripheral smear; Urine routine & microscopy; Stool examination for ova, cyst, pH(lactose intolerance); PPD (for TB); Total sr protein & albumin; Blood urea/ creatinine 

(already done and planned in future)

Clinico-social diagnosis:

This is the family of Mr.____________residing in ________ (name of the area), having 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?)

Comprehensive management plan: