SOCIO-CLINICAL CASE PRESENTATION

(FORMAT)
Basic Demographic Details

• Name:
• Age:
- In completed years
- In case of children < 2years, write age in months.
• Gender:
• Religion:
• Complete address: (House no., Street, Locality, Ward no.)
- To assess on certain epidemiological factors like
epidemic/ endemic nature, geographic trends, follow-up)
Basic Demographic Details (contd.)

• Type of family: Nuclear/Joint/Three generation/Broken/

Problem
• Education level
• Occupation:
- Nature of job: Sedentary/Moderate/Heavy
- Type of job: Unskilled/Semi-skilled/Skilled
• Marital status:
• Income:
• Nearest health facility:
• Social insurance scheme:
• Sedentary worker
- Mostly resting with little or no planned strenuous activity
- Eg: Bank employees, Software engineers

• Moderate worker
- Mostly standing or walking work environment
- Eg; Teacher, Watchmen, Factory employees

• Heavy worker
- Working environment is strenuous for several hours
- Eg: Rickshaw pullers, Daily construction workers
• Unskilled worker
- Does works that involve the performance of simple duties
that require the experience of little or no previous
experience or skills
- Eg: Peon, Watchman, Sweeper
• Semi-skilled worker
- Does work of defined routine nature wherein some
judgement and skill are required & important decisions
are made by others
- Eg; Security guards, Waiters, Taxi drivers
• Skilled worker
- Capable of working efficiently exercising considerable
independent judgement
- Eg: Nurses, Tailors, Electricians
 Family details
S. Name Relatio Age/ Marital Educati Occupa Income Similar
N. n with Gen status on tion (monthl illness
HoH der y)
1. Ram Karki HoH 55/ Married Class 8 Farmer Rs. Yes
M 20000
2. Maya Karki Wife 48/F Married Class 3 Homem -- No
aker
3. Shiva Karki Son 25/ Married SLC Migrant Rs. No
M worker 50000
4. Devi Karki Daught 24/F Married SLC Shopke Rs No
er-in- eper 10000
law
5. Shyam Grand 18 NA NA NA -- No
Karki son mo/
M
 Family details (contd.)

➢Head of the household should always be written in the top

of the chart followed by other members as per the hierarchy.

➢Financially supporting family members who are working

abroad and are in contact, are to be included in the family.

➢For family members less than 10 years old, marital status

and occupation aren’t applicable.

➢For family members less than 6 years old, education isn’t

applicable.
 IMPORTANT QUESTIONS IN FAMILY HISTORY!!!

➢Define family

➢Difference between family and household

➢Types of family

➢Advantages and disadvantages of different types of family

➢Functions of family

➢Problem family, broken family, their consequences

➢Role of family in health and disease

Chief complaints: In chronological order

History of presenting illness

- Elaborate the chief complaints (duration, mode of onset,

progression, severity, aggravating and relieving factors)

Past history
- H/o Tuberculosis
- Systemic hypertension
- Diabetes Mellitus
- Any other chronic medical condition
- Previous surgeries
- Complications due to the illness
 Personal history
• Smoking (duration, age started smoking, type (cigar/beedi/
filtered), frequency per day)

• Alcohol (duration, age started, type of alcohol, frequency and

quantity per day)

• H/o any drug abuse (name of the drug, frequency of use,

duration, any withdrawal symptom)

• Diet: Vegetarian/Non-vegetarian

• Bowel/Bladder habits: Altered/Normal

• Sleep, Appetite
Socio-economic history
• Total family income: Rs. 80,000/month

• No debts

• Family is above poverty line.

• Socio-economic status: Upper Middle class (Modified

Kuppuswamy scale)
 Per capita income
Total family income (per month)- Rs. 80,000
Per capita income = Rs. 80,000 x 12 months
= Rs. 9,60,000/5 (family members = 5)
= Rs. 1,92,000/person/year
= Rs. 1,92,000/365
= Rs. 526.03/person/day
= Rs. 526.03/128 (1$ = Rs.128)
= $ 4.11/person/day (above poverty line)

Per capita income: ≥ $2.15/head/day (Above poverty line)

Per capita income: < $2.15/head/day (Below poverty line)
 Socio-economic status scale
• Modified Kuppuswamy scale: in urban and peri-urban areas

• Modified BG Prasad’s scale: in both urban and rural areas

• Uday Pareekh scale: rural areas

 Modified Kuppuswamy scale
• Used for determining SES in urban and peri-urban areas

• Use of 3 parameters:

- Education of HoH

- Occupation of HoH

- Total family income

 Environmental history

• Type of house (Pucca/Semi- • Ventilation: adequate/

pucca/Kuccha) inadequate

• Situation/Location • Lighting: adequate/inadequate

• Set back (Present/Absent) • Cross-ventilation

• Floor, roof, walls, windows • Separate kitchen: Yes/No,

• No. of rooms Method of storage of food, Fuel

used, Exhaust +/-
• Overcrowding
• Garbage disposal
• Accident-prone areas
Environmental history (contd.)

• Separate toilet

• Habit of open defecation

• Solid waste: storage, disposal

• Water: source, storage, purification method

• Fly/Mosquito/Sandfly breeding source +/-

• Pest/Rodent menace +/-

• Pet animals: +/-, immunization, housing, cleaning, excreta

disposal of animals
 IMPORTANT QUESTIONS IN ENVIRONMENTAL
HISTORY!!!

➢Housing standards ➢Cross-ventilation

➢Solid waste disposal methods ➢Diseases transmitted due to

➢Excreta disposal methods housing conditions

➢Sanitation barrier ➢Water purification methods

➢Overcrowding criteria

➢Adequate/Inadequate
ventilation, lighting
 Types of house

1. Pakka (Permanent)-all roof, walls and floor are constructed

with permanent construction material like cement, brick,
concrete, stone, etc.

2. Semi Pakka (Semi-permanent)-if either of the wall, floor or

roof is constructed without concrete material.

Roof Wall

a)Tin Brick, Concrete

b)Thatched Brick,Concrete,Stone

c)Tiled Concrete, Brick

3. Kachcha (Temporary)-all roof, floor or wall is constructed
without concrete material like wooden flakes, bamboo, straw,
mud.

E.g.-

Roof Wall/floor

a)Tin bamboo(thatti), mud

b)Tiled mud wall

• Adequate lighting: A room is adequately lighted when one can
read or write in any corner of the room without the help of
artificial light during day time.

• Adequate ventilation: Every room should be provided with at

least two windows and one of them should open directly to
and open space.

• Cross-ventilation: Doors and windows should be placed

opposite to each other so that air can pass through one end
and come out at the other.
 Overcrowding criteria

1. Persons per room:

1 room = 2 persons
2 rooms = 3 persons
3 rooms =5 persons
4 rooms = 7 persons
5 or more rooms = 10 persons (additional 2 for each further
room)

2. Sex separation: 2 persons over 9 years of age, not husband and

wife, of opposite sexes are obliged to sleep in the same room.
 Overcrowding criteria (contd.)
3. Floor space:

110sq.ft (11 sq.m) or more – 2 persons

70-90 sq.ft. (7 – 9 sq.m.) –1 person

50 – 70 sq.ft (5 -7 sq.m.) – ½ person

Under 50 sq.ft (5 sq.m.) – nil

A baby under 12 months – not counted

Children between 1 to 10 yrs - counted as half a unit

>10yrs- counted as one unit

Contact history

• H/o similar symptoms in close contacts

Dietary history

• Use 24 hours recall method: ask the patient about his diet
consumed the day before

• Compare it with the reference standard (RDA for that particular

age and gender group)

• Comment on excess/deficit of calorie and protein intake

Dietary history (24 hour recall method)
Meal Food items Quantity Calories Proteins
(Kcal) (g/day)
Breakfast Tea 1 cup 30 1
Paratha 1 piece 280 5
Lunch Rice 2 cups 400 8
Pulses 1 cup 200 10
Mixed vegetables ½ cup 75 2
Snacks Tea 1 cup 30 1
Chick peas 1 cup 270 15
Evening Tea 1 cup 30 1
Dinner Rice 2 cups 400 8
Pulses 1 cup 200 10
Mixed vegetables ½ cup 75 2
Total 1990 63
Calories: Protein:

Consumed: 1990 Kcal/day Consumed: 63 gm/day

Requirement: 2110 Kcal/day Requirement: 54 gm/day

Deficit: 120 Kcal/day Surplus: 9 gm/day

Deficit percentage: 5.7% Surplus percentage: 16.7%

If deficit/surplus is > 20%, then dietary recommendations

should be given.
 IMPORTANT QUESTIONS IN DIETARY HISTORY!!!

➢Need for nutritional assessment

➢Methods of nutritional assessment

➢Methods of assessment of dietary intake

➢One dietary cycle

➢Recommended Daily Allowances for calorie, protein for

different age and gender groups

➢Reference man and woman

 Nutritional Assessment Why?

Identify individuals or population groups at risk of becoming

malnourished

Identify individuals or population groups who are malnourished

To develop health care programs that meet the community

needs which are defined by the assessment

To measure the effectiveness of the nutritional programs &

intervention once initiated
 Methods of Nutritional Assessment

Nutrition is assessed by two types of methods;

• Direct

• Indirect

The direct methods deal with the individual and measure

objective criteria, while indirect methods use community health
indices that reflects nutritional influences.
 Direct Methods of Nutritional Assessment

A. Anthropometric methods: Height, Weight, BMI, MUAC

B. Biochemical, laboratory methods: Analysis of blood, urine and

other body tissues

C. Clinical methods: Complete physical examination, medical and

psychological history

D. Dietary evaluation methods: foods and quantities eaten,

eating habits, accessibility of foods, cultural and socioeconomic
factors that affects in selection of foods
 Indirect Methods of Nutritional Assessment

• Ecological variables including crop production

• Economic factors e.g. per capita income, population density

& social habits

• Vital health statistics particularly infant & under 5 mortality

& fertility index
 Dietary Intake Assessment

1. 24 hours Dietary recall

2. Food frequency questionnaire

3. Dietary history since early life

4. Food diary technique

5. Observed food consumption

24 Hours Dietary Recall

• A trained interviewer asks the subject to recall all food &

drink taken in the previous 24 hours

• It is quick, easy, & depends on short-term memory, but may

not be truly representative of the person’s usual intake

Food Frequency Questionnaire

• Subject is given an extensive list of food items to indicate

his/her food intake (frequency and quantity)

• Needs regular update to keep pace with changing dietary

habits
Foods are nutritive materials
taken into the body for
the maintenance of life
and the growth
and repair of
tissues.
 Dietary history since early life
• Trained interviewer collects details about usual intake, types,
amount, frequency & timing needs to be obtained

Food Diary
• Food intake (types & amounts) should be recorded by the
subject at the time of consumption
• Recorded for 1-7 days period

Observed Food Consumption

• The meal eaten by the individual is weighed and contents are
exactly calculated
• Recommended for research purposes
Socio-cultural history (Pertaining to the case)
• Knowledge about the disease

• Attitude towards the disease

• Practice: System of medicine (Indigenous/Home

remedy/Allopathy)
Other Important Histories (Case Specific)
• Immunization History, Developmental History: Under-5
children/Severe malnutrition

• Drug/Treatment history: Name, dose, duration, frequency

• Menstrual History: ANC/PNC/Female, Cycle, Blood flow, Change

of pads, etc.

• Obstetric history: GPLA, Mode of delivery in previous children,

Any complications

• Dietary history for infants: when was breast feeding started, pre-
lacteal feeds, colostrum given or not, exclusive BF, weaning
General Physical Examination
Systemic Examination
Investigations
Diagnosis
• Provisional Diagnosis: about the disease in the individual

• Community Diagnosis: includes relevant familial, social, cultural,

environmental, economic factors associated with disease
causation
 Provisional Diagnosis

55-year old male presenting with chronic non-healing wound on

the right foot is diagnosed to have Type 2 Diabetes Mellitus with
complications (Peripheral Neuropathy)
 Community Diagnosis

55-year old obese male presenting with chronic non-healing

wound on the right foot, coming from lower socio-economic class
joint family (according to Modified Kuppuswamy scale) of an urban
slum in an overcrowded house and working as a labor, consuming
high calorie for his age and gender, a chronic alcoholic with poor
knowledge on diabetes treatment and not under any kind of
allopathic medication was diagnosed with Type 2 Diabetes
Mellitus with peripheral neuropathy.
Management (Medical and Social: Preventive, Promotive
and Curative measures)

a) Individual level: Treatment, Advice to patient

b) Family level: Support and disease awareness

c) Community level: Relevant national health programs and

benefits