DEPARTMENT OF COMMUNITY MEDICINE 

DHANALAKSHMI SRINIVASAN MEDICAL COLLEGE & HOSPITAL 

CLINICAL SOCIAL CASE STUDY 
 
I. PATIENT DEMOGRAPHIC DETAILS 
 
1. Name: 2. Age : 3. Sex: 
 
4. Marital Status: 5. Religion: 6.Education:  
 
7. Address: 8. Occupation: 
 
9. Date of Admission: 10. OP / IP No. : 
 
11. Ward:  
 
II: FAMILY DETAILS 
 
Family composition 
S.no  Name  Age/gend Relation  Edu  Occu  Monthl Immunisatio
er  to index  y  n status if 
case  Income  needed 
               
               
               
 
   
1. Type of Family: Nuclear / Joint / Three Generation 
Dependency ratio 
Vital events in the family {Past 1 years}-Birth/Death 
 
2. Total family Income per month : Rs.  
 
 
3. Per Capita Income per month : Rs    
   
 
4. Socio Economic Scale used: 
 
Modified Kuppuswamy (Urban) 
Modified B G Prasad (Rural) 
   
III. CLINICAL DETAILS: 
 
 
A. History: 
 
1. Chief Complaints : 
 
 
2. History of Present illness : 
 
The patient was apparently normal. Complaints started as 
 
Symptoms  onset  duration  Progression  Relieving  Aggressing 
factors  factors 
           
 
With negative history 
 
With history to rule out complications and severity/grading. 
Differential diagnosis and related history 
 
3. Treatment History :   
(Before Admission) 
Details regarding name of drug, dosage and frequency 
 
History of treatment for similar illness in the past 
 
4. 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] 
 
Health care contact after 1st symptom appears:[write in a chronological 
order] - acute diseases 
 
Period delay [if delay is present-ask for reason] /Place/treatment taken/ 
referral/improvement status 
 
What was the first health care contact?…………….Distance?............ 
When was the first health care contact after the first symptom?………………. 
Was it immediate?………If it was not immediate,what was the reason? 
Any treatment taken at home?……………. 
Was there an improvement after the next health care taken? 
What was the treatment? 
If not,what was the next health care contact? 
  
5. Past History : 
  Whether  h/o  DM,  HTN,  Cardiovascular  disease,  stroke,  epilepsy, 
tuberculosis, bronchial asthma 
History of drug allergy 
 
6. Family History : 
Relevant Family History (Non Communicable Disease): 
Any similar case in the family / Neighbourhood (Contact tracing)  
 
7. Personal History : 
 
Behaviour (alcohol / smoking / tobacco chewing / any other high risk factors): 
 
8.Menstrual history in females 
Menarche 
Cycles regular 
Frequency 
   
9. Diet History: 
 
Type of diet : veg/non-veg/mixed 
Staple food 
 Frequency of non veg per week 
Frequency of fruits usage per week 
Oil usage per month 
According to 24 hour dietary recall method 
 
  
Timing  meals taken  Calorie  Protein 
Morning ….       
Breakfast       
at 11pm       
Lunch       
Evening       
Dinner       
 
 
Nutritional Aspect  Daily Requirement  Daily Intake 
Energy (KCal)     
Protein (Grams)     
 
Comments & Suggestions: 
 
IV. Socio Environment Factors: 
Environment: 
 
a) Housing  
Type : Pucca/ Katcha/ Semi pucca 
Overcrowding  
Lighting  
Ventilation  
Cross ventilation 
 b) Water Supply :  
Source 
Household method of purification 
Adequacy 
Storage 
c) Latrine Facility  :  
d) Solid Waste Disposal : 
(Collection-method,frequency/disposal-site,distance) 
e) Kitchen and cooking fuel used : 
Kitchen platform present or absent 
Type  of  fuel  used  for  cooking  predominantly:  wood__/  LPG________/ 
electricity___________ 
f) sullage and sewage disposal: 
g) Hand washing practices: 
h) Pets in the family: 
i) Others (Specify, e.g.: Vector Breeding Sites ) : 
 
Knowledge, Attitude and Practice of the Patient towards this Disease: 
 
(Belief / Social taboos / Cultural practices etc.) 
 
Attitude of the family towards the patient : 
 
Attitude of the society towards the patient (as relevant) : 
 
Availability and Utilization of Health Services :  
 
Effect of illness in the family: 
 
a) Financial : 
b) Social : 
 c) Psychological  
SUMMARY 
 
_yr  old  patient  coming  from-----  belonging  o a socioeconomic class of ___from a 
___type of family__with complaints of __ 
 
Significant history in medical and socio-environment area 
 
V. Physical Examination 
 
General Examination​: 
 
Pallor  /  Icterus  /  Cyanosis  /  Pedal  oedema  /  Lymphadenopathy  / 
Clubbing  
 
Pulse: Blood Pressure: RR:
 
Weight: Height: B.M.I.:
   
 
Hip  /  Waist  Circumference/Waist  Hip  Ratio  -  particularly  in  Diabetes  mellitus 
and Hypertension 
 
Any other Relevant findings: 
 
Systemic Examination​: 
 
RS 
CVS 
CNS 
Per abdomen 
 
Foot examination in diabetics 
Look: ulcer,nail,cracks,color change 
  Feel  :  Temperature  difference,  dorsalis  pedis  artery  and  posterior  tibial  artery 
pulsation, vibration sense 
 
 
 
 
 
Diagnosis: 
 
_yr  old  patient  coming  from-----  belonging  to  a  socioeconomic  class  of 
__diagnosed with ____ 
 
 
Investigations (Done / Required): 
 
 
Discussion: 
 
 
1. What are the Social factors responsible for present condition of the 
patient? 
 
2. What are the factors that made the patient to come to this Hospital?  
 
3. Which  level  of  prevention  has  failed  in  this  patient?  Justify  your 
statement. 
 
Management  (Medical  &  Social  -  Preventive  /  Promotive  /  Curative 
measures): 
 
 
 
a) Individual Level: 
 
 
b) Family Level: 
 
 
c) Community Level: 
 
 
Relevant National health programme concerned to this case   
 Social Obstetrics (Antenatal Case) 
  
  Date: 
I. Personal Details: 
  
1. Name:  2. Age: 
  
  
3. Address: 
  

  
4. Religion:    5. Education:  6. 
Occupation: 
  
  
7. Date of Admission :  8. Ward:    9. OP / IP No: 
  
II: FAMILY DETAILS 
  
Family composition 
S.no  Name  Age/gend Relation  Edu  Occu  Monthl Immunisati
er  to index  y  on status if 
case  Income  needed 

                       

                       

                       
  
 
1. Type of Family: Nuclear / Joint / Three Generation 
  
2. Total family Income per month  : Rs.   
  
3. Per Capita Income per month  : Rs     
   
4. Socio Economic Scale used 
Modified Kuppuswamy (Urban) 
Modified B G Prasad (Rural)  
III. Clinical Details:   
   
A. History: 
  
1. Present Complaints (Obstetrics): 
  
2.  Present  History:  (Antenatal  Care  for  present  pregnancy  -  Registration,  Inj. 
TT, IFA, Visits etc.): 
  
Registered / Un Registered   
  
Obstetrics Status:   
Gravida:  Para:.  Live birth :  Abortion:  Still birth: 
  
LMP: Last month of period  EDD: Expected date of delivery 
 
I Trimester  : 
II Trimester   
III Trimester : 
  
3. Past History (Obstetrics): 

Pregnan Place of  Problems  Place of  Details of Child  FP 

cy  Antenata &  Deliver
Order  l Care  Managem y  Sex  Presen Health  Method
ent during  t  status 
Pregnancy  Age  s 
/ Delivery  ( 
years )  Adopte

d 

  
1st               

2nd               

  
Age at Menarche:   
Age at Marriage:     
Age at First Pregnancy: 
  
4. Past History of other illness (Medical / Surgical) if any: 
​ 5​ . Health care delivery assessment 
Nearest health facility:Sub centre:………… Kms…….. 
 
PHC/CHC/GH/GP/Private hospital: Kms…….. 
 
  
M
​ enstrual History​- Cycles: Regular / Irregular  Duration of Cycle: 
  
  

Personal History: 
   
  Behaviour (tobacco chewing / alcohol / any other): 
   
​ Diet History: 
  
  Type of diet : veg/non-veg/mixed 
Staple food 
Frequency of non veg per week 
Frequency of fruits usage per week 
Oil usage per month 
According to 24 hour dietary recall method 
 
Timing  meals taken  Calorie  Protein 

Morning ….          

Breakfast          

at 11pm          

Lunch          

Evening          

Dinner          
  
  
 Nutritional Aspect  Daily Requirement  Daily Intake 

Energy (KCal)       

Protein (Grams)       

  
Comments and Suggestions: 
IV. Socio Environment Factors: 
 
j) Housing  
Type : Pucca/ Katcha/ Semi pucca 
Overcrowding  
Lighting  
Ventilation  
Cross ventilation 
k) Water Supply :  
Source 
Household method of purification 
Adequacy 
Storage 
l) Latrine Facility  :  
m) Solid Waste Disposal : 
(Collection-method,frequency/disposal-site,distance) 
n) Kitchen and cooking fuel used : 
Kitchen platform present or absent 
Type  of  fuel  used  for  cooking  predominantly:  wood__/  LPG________/ 
electricity___________ 
o) sullage and sewage disposal: 
 p) Hand washing practices: 
q) Pets in the family: 
r) Others (Specify, e.g.: Vector Breeding Sites ) : 
Knowledge, Attitude & Practice of the Mother related to Pregnancy: 
1. Awareness / Belief on 
Mother’s Nutrition  : 
Iodized salt  : 
Breast feeding  : 
Immunization  : 
Vitamin – A Prophylaxis : 
FP method  : 
Aganwadi Centre  : 
Personal Hygiene  : 
Any other (Relevant) : 
Warning Signs : 
  
  
2. Attitude of the mother towards this pregnancy  : 
  
  
3. Attitude of the family towards this pregnancy  : 
  
  

  
4. Cultural Practices during Pregnancy  : 
  
  
  

5. Utilization of Health services  : 

   
SUMMARY 
  
_yr  old  patient  coming  from-----  belonging  o a socioeconomic class of ___from a 
___type of family__with complaints of __ 
  
Significant history in medical and socio-environment area 
  
  
  
  
B. Physical Examination: 
  
General Examination: 
  
Pallor / Icterus / Cyanosis  /  Pedal  oedema  /  Lymphadenopathy  / 
Clubbing   
Any other relevant finding 
Weight:  Height:     
Weight Gain during Pregnancy: 
V
​ ital Signs:   
  

Temp :  Pulse:    Blood Pressure : 

  

Systemic Examination: 
  

1. Abdomen  
Inspection: 
 
Palpation:   
Fundal Height  : 
Abdominal girth : 
Fundal grip, lateral grip. first pelvic grip, second pelvic griP 
Auscultation (FHR) : 
2. Other Systems: 
  CVS:    RS : 
CNS: 
   
Breast Examination    :   
​ Diagnosis 
Stated as G,P,L,A in ___ weeks of gestation with normal pregnancy or pregnancy 
complicated by____ 
Mention both medical and socio-cultural factors which affect it. 
Mention whether components of essential care received or not. 
Lab Investigations: 
Blood:  Hb%:  Group & Rh type:  HIV:  
  Others : 
Urine :  Albumin:    Sugar:   
Microscopy: 
Stool : Ova / Cyst   
Other Investigations (if required – e.g. Malaria, HBSAg, Hepatitis C): 
​Discussion: 
1.​ ​What are the relevant Social factors influencing the condition of the mother ? 
2. Factors which made the person come to this Hospital ? 
3. Comment on the Level of prevention for this mother. 
 
Management  (Medical  &  Social  -  Preventive,  Promotive  &  Curative 
Measures): 
a. Individual Level : 
  b. Family Level    

  c.  Community  Level:  (Community  Activities  in  implementing  relevant 

National Programs) 

Relevant National health programme concerned to this case 

 
 
 
 
 
 
 
​ ​Social Obstetrics (Postnatal Case) 
  
  
  

  Date : 
I. Personal Details: 
  
1. Name:  2. Age: 
  
3. Address: 
  

4. Religion:  5. Education: 6. 

Occupation: 
  
7. Date of Admission :  8. Ward:    9. 
OP / IP No: 
​II: FAMILY DETAILS 
  
Family composition 
S.no  Name  Age/gend Relation  Edu  Occu  Monthl Immunisati
er  to index  y  on status if 
case  Income  needed 

                       

                       
  
 
1. Type of Family: Nuclear / Joint / Three Generation 
  
2. Total family Income per month  : Rs.   
  
  
3. Per Capita Income per month  : Rs     
   
4. Socio Economic Scale used 
Modified Kuppuswamy (Urban) 
Modified B G Prasad (Rural) 
 
 
III. Clinical Details:   
A. History: 
  
1. Present Complaints (Obstetrics): 
  
2. Present History (Obstetrics)  : 
Obstetrics Status: Para:  Live birth :    Abortion :    Still 
birth:   
  
High Risk Case  :  Yes  /  No  If Yes, Risk factor : 
  
Referred Case  :  Yes  /  No   If Yes, Referred from / by 
: 
Details of delivery: 
(Date, Time, Place, Mode, Conducted by, Time from Rupture of Membranes to 
delivery, Complications etc.) 
  
Postnatal period 
  
Baby: ​Initiation of breast feeding 
  Any prelacteal feeds 
  Feeding pattern 
  Immunisation 
  Stools/Urine 
  
Mother: F ​ever/ burning micturition/lochia condition/lower abdominal 
pain/breastfeeding 
  
History of present pregnancy 
Antenatal Care for the present pregnancy (Registration, Inj. TT, IFA, Visits 
etc.): 
LMP:  EDD:   
Registered / Un Registered 
  
I Trimester  : 

II Trimester   

III Trimester : 
3. Past History (Obstetrics): 

Pregnan Antenata Problems  Place  Details of Child  FP 

cy  l Care  &  of 
Order  Managem Deliver Sex  Presen Health  Method
ent during  y  t Age  status 
Pregnancy  (years)  s 
/ Delivery 
Adopte

d 

  
1st               
2nd               
  
Age at Menarche:  Age at Marriage:    Age at First 
Pregnancy: 
  
4. Past History of other illness (Medical / Surgical) if any: 
  
 
  

​Menstrual History​- Cycles: Regular / Irregular  Duration of Cycle : 

  
​Personal History​: 
   
  Behaviour (tobacco chewing / alcohol / any other) 
​ Diet History: 
  
  
Type of diet : veg/non-veg/mixed 
Staple food 
Frequency of non veg per week 
Frequency of fruits usage per week 
Oil usage per month 
 
 
 
 According to 24 hour dietary recall method 
 
Timing  meals taken  Calorie  Protein 

Morning ….          

Breakfast          

at 11pm          

Lunch          

Evening          

Dinner          
  
  
  
  

Nutritional Aspect  Daily Requirement  Daily Intake 

Energy (KCal)       

Protein (Grams)       

  
Comments and Suggestions: 
IV. Socio Environment Factors: 
Environment: 
 
s) Housing  
Type : Pucca/ Katcha/ Semi pucca 
Overcrowding  
Lighting  
Ventilation  
Cross ventilation 
t) Water Supply :  
 Source 
Household method of purification 
Adequacy 
Storage 
u) Latrine Facility  :  
v) Solid Waste Disposal : 
(Collection-method,frequency/disposal-site,distance) 
w) Kitchen and cooking fuel used : 
Kitchen platform present or absent 
Type  of  fuel  used  for  cooking  predominantly:  wood__/  LPG________/ 
electricity___________ 
x) sullage and sewage disposal: 
y) Hand washing practices: 
z) Pets in the family: 
Others (Specify, e.g.: Vector Breeding Sites ) :  
Knowledge, Attitude & Practice (Postnatal Care) 
1. Awareness / Belief on 
Family Planning methods  : Wife: Yes / No  Husband: 

Yes / No 

Mother’s Nutrition  : 

Breastfeeding  : 

Immunization  : 

Vitamin A Prophylaxis  : 
  
Under Five Clinic  : 
  
Anganwadi Centre  : 
  
ARI / Diarrheal Diseases Preventive measures: 
  
Any other (Relevant) Iodized Salt : 
  
  
2. Attitude of the mother towards this pregnancy : 
  
  
3. Attitude of the family towards this pregnancy : 
  
  
4. Practices during Postnatal period (Nutrition, Hygiene, Childrearing etc): 
  
  
5. Any Family Planning method adopted (past / present): 
  
SUMMARY 
  
_yr  old  patient  coming  from-----  belonging  o a socioeconomic class of ___from a 
___type of family__with complaints of __ 
Significant history in medical and socio-environment area 
  

B. Physical Examination (Mother): 

  
General Examination: 
  
Pallor / Icterus / Cyanosis  /  Pedal oedema  /  Lymphadenopathy  / 
Clubbing   
  
Any other relevant finding: 
  
Weight:  Height:  
Vital Signs:   
Temp :    Pulse:  Blood Pressure :   
Systemic Examination: 
  

1.​ ​a) Abdomen​ : 

  
  Inspection: 
  
Palpation: 
  
  
  b) Vaginal discharge / Lochia: 
  
  
2. Other Systems: 
   
  CVS: RS :    CNS: 
  Breast Examination: 
C. Lab Investigations: 
New Born Baby (Information & Physical Examination): 
  

a) Gender:  b) Birth Weight:  c) Length:   

d) APGAR: 
e) Any Congenital Abnormality:   
  

Head  anterior fontanelle/caput 

Skin  vernix/mongolian spots/other lesions 

eyes  discharge/excessive tears/icterus 

mouth    

neck/chest    

hands    

abdomen    
(f) Umbilical Cord:     
(g)Heart rate:   
(h) Respiratory rate:   
(i)Breastfeeding started? Yes / No; When started? Any problem, specify 
(j)Prelacteal feed given, if any: 
(k)Immunization: BCG:  OPV (Zero dose): 
(l) Lab Investigations : 
Diagnosis: ( Mother & Baby) 
​Discussion: 
  
1.​ ​What are the relevant Social factors influencing the condition of the mother? 
  
2. Factors which made the person come to this Hospital? 
3. Comment on the Level of prevention for this mother. 
  
Management (Medical & Social – Preventive, Promotive & Curative 
Measures) 
  
  

  a. Individual Level : 

  b. Family Level   

c. Community Level  : (Community Activities in implementing 

relevant National Programs 

Relevant National health programme concerned to this case 

 
  
 
 
 
 
  
 Social Pediatrics 
  
  
  

  Date : 
1. Patient Details 
  
1. Name  :  2. Age  :  3. Sex: 
  
4. Address  : 
  

   
5. Religion  :  6. Education :   
  
7a. Date of Admission  :  7b.Ward  : 
7c. OP / IP No: 
  
8. Informant  : 
  

I​ I: FAMILY DETAILS 
  
Family composition 
S.no  Name  Age/gend Relation  Edu  Occu  Monthl Immunisati
er  to index  y  on status if 
case  Income  needed 

                       

                       
   
1. Type of Family: Nuclear / Joint / Three Generation 
  
2. Total family Income per month  : Rs.   
  
3. Per Capita Income per month  : Rs     
   
4. Socio Economic Scale used 
Modified Kuppuswamy (Urban) 
Modified B G Prasad (Rural) 
 
 
 
1I1. Clinical Details:   
  
A. History: 
  
1. Presenting Complaints    : 
2. History of Present Illness  : 
3. Treatment History (before admission): 
4. Past History (Relevant)    :   
5. Any other family member suffering from similar illness? 
 
​Birth History  : 
  
    Institutional / Domiciliary Delivery : 
   
  Birth Order: 
  
  Antenatal : 
  
  Natal  : Birth Weight  
  Mode of Delivery : Gestational Age: 
   
  APGAR (if relevant)  : 
​Immunization​: (with dates) 
  
BCG / OPV  :  Measles  : 
     
OPV  : 1 / 2 / 3 / 4 / 5  MMR  : 
     
DPT  : 1 / 2 / 3 / B  Hepatitis  : 1 / 2 / 3 
     
Typhoid  :  Others  : 
     
  

  
Developmental Milestones​: 
​Personal History  : 
  
  a. Hygiene  : 
  
b. Diet History 
  
    Breast Feeding : 
Weaning  :    
​ Diet History: 
  
Type of diet : veg/non-veg/mixed 
Staple food 
Frequency of non veg per week 
Frequency of fruits usage per week 
Oil usage per month 
According to 24 hour dietary recall method 
  
  
  
Timing  meals taken  Calorie  Protein 

Morning ….          

Breakfast          

at 11pm          

Lunch          

Evening          

Dinner          
  
Nutritional Aspect  Daily requirement  Daily intake 

Energy (in K. Cal)       

Protein (in Grams)       

  
Comments and Suggestions: 
  
 
Knowledge, Attitude & Practice of Caretaker (Related to Present illness) 
1. Awareness / Belief (Cause, Mode of spread, Prevention; etc.) 
ARI  : 

Diarrhoeal Disease  : 

Worm Infestation  : 

Vit. A Deficiency  : 

Iodized Salt  : 

Growth Monitoring  : 

Anganwadi Centre  : 

Under Five Clinic  : 

Child Guidance Clinic  : 

2.  Attitude of caretaker towards the child’s illness. 

  
3.  Practices of caretaker (related to Child’s illness, Nutrition, Health services 
utilization etc.) 
  
SUMMARY 
  
_yr  old  patient  coming  from-----  belonging  o a socioeconomic class of ___from a 
___type of family__with complaints of __ 
Significant history in medical and socio-environment area 
 
B. Physical Examination: 
  
​General Examination : 
  
Pallor / Icterus / Cyanosis  /  Pedal oedema  /  Lymphadenopathy  / 
Clubbing   
   
Other Findings: (AF, Grunting, Dehydration, Rash , Malnutrition etc.)  
Anthropometry : 

   Present  Expected 

Weight       

Height       

Head Circumference       

Chest Circumference       

Mid Arm Circumference       

  
Nutritional Grade (IAP Classification): 
Vital Signs :  
Temp :    Pulse: Blood Pressure : 
Respiration: 
​Systemic Examination: 
  
Diagnosis  : 
  _yr old patient coming from----- belonging to a socioeconomic class of 
__diagnosed with ____ 
​Investigations  : 
  
Discussion: 
  
  
1.  Relevant Social and Environmental factors influencing the condition of 
the Child. 
  
2.  Factors which made the person come to this Hospital? 
  
3.  Which levels of prevention have failed in this case? Justify your statement. 
  
  
  
Management (Medical & Social – Preventive, Promotive & Curative 
Measures) 
  
  
a. Individual level  : 

  

b. Family level   : 

  

c. Community level  : (Community Activities in implementing relevant 

National Programs): 

 
Relevant National health programme concerned to this case