CLINICO-SOCIAL CASE DISCUSSION - CD / NCD

CASE NO.: _______ DATE: _______________

1. PARTICULARS OF THE PATIENT:

Name-
Age/Gender-
Residence-
Educational qualification- DOA :
Occupation- DOE :

2. CHIEF COMPLAINTS

3. HISTORY OF PRESENTING ILLNESS

4. MEDICAL HISTORY
5. PAST HISTORY

6. FAMILY HISTORY

Total no. of members living in the family

Type of family
Pedigree chart

7. PERSONAL HISTORY

Diet-
Appetite
Sleep
Bowel and bladder
Habits
H/o substance abuse

8. DIET HISTORY

By 24 hour pre-illness recall method,

Principles Required Intake Deficit

Calorie (kCal/day)

Protein (gm/day)

9. GENERAL PHYSICAL EXAMINATION

A _____ year old _______ patient, is conscious, co-operative, well oriented to time, place and person.

VITALS:
Temperature
Pulse rate (Rate/Rhythm/Volume/Character/Radio-radial delay/Radio-femoral delay/PP/Condition of vessel wall)
Respiratory rate (Rate/Type of respiration/Accessory muscles involvement)
Blood pressure
SpO2

ANTHROPOMETRIC MEASUREMENTS
Weight - Height - BMI=

WC= Waist-Hip ratio=

Pallor | Icterus | Clubbing | Cyanosis | Lymphadenopathy | Edema

10. SYSTEMIC EXAMINATION:

1. RESPIRATORY SYSTEM
Position of the patient-
a. Upper respiratory tract
Nose(nasal cavity/nasal septum/) / PNS(Tenderness) / Oral cavity / Oropharynx(Tonsils/PPW)
b. Lower respiratory tract
I. INSPECTION
Shape and symmetry of chest
Bony cage
Respiration- rate/rhythm/depth of respiration/type of respiration
Position of trachea
Apex beat
Spine
Expansion of chest-

Chest wall retraction

Accessory muscles
Visible pulsations/sinus/scars
Other findings
II. PALPATION
Temperature / Intercostal tenderness
Confirmation of all inspectory findings: Spine(Position/tenderness)
Position of trachea
Apex beat
Expansion of chest- Measurements-
Vocal fremitus-

Tactile fremitus-
III. PERCUSSION
Note heard-

Dull note heard from(upper border of liver)

Liver span
Cardiac dullness: Right heart border-
Left heart border-

IV. AUSCULTATION

4. Adventitious sounds
2. CARDIOVASCULAR SYSTEM - Examination of precordium
I. INSPECTION
Shape and symmetry of chest
Precordial prominence
Cardiovascular pulsations
a. Apical pulse
b. Suprasternal
c. Epigastric
d. Carotid
Spine
Dilated and engorged veins (over precordium/neck)
II. PALPATION
Temperature
Apical beat (Position/Character-rate, rhythm, force)
Carotid pulsations
JVP
Thrills
III. PERCUSSION
Right cardiac border
Left cardiac border
Area of cardiac dullness
IV. AUSCULTATION

MURMUR -

Timing
Grade
Quality
Pitch
Configuration
Radiation
Best heard with diaphragm or bell
Patient position
With breath held in inspiration or expiration
Dynamic auscultation

3. PER ABDOMEN

4. CENTRAL NERVOUS SYSTEM

11. INVESTIGATIONS

12. CLINICAL DIAGNOSIS

13. SOCIO-ECONOMIC HISTORY

● Modified B. G. Prasad classification scale

Total income of the family (Rs./month) =
Total no. of members in the family =
Per-capita monthly income =

SOCIAL CLASS Per-capita monthly income

I- UPPER 7889 & above

II- UPPER MIDDLE 3944-7888

III- LOWER MIDDLE 2367-3743

IV- UPPER LOWER 1183-2366

V- LOWER Below 1183

.’. According to modified B. G. Prasad classification, the patient belongs to ___________________

14. ENVIRONMENTAL HISTORY

ASSESSMENT OF LIVING CONDITION:

POOR (0-7) SATISFACTORY (8-15) GOOD (16-22)

15. K-A-P ASSESSMENT

a. Health knowledge of the disease - Good / Bad

b. Attitude towards disease - Positive / Negative

c. Practices - Good / Poor

16. CLINICO-SOCIAL DIAGNOSIS

17. ADVICE

a. Individual level -

b. Family level -

c. Community level -

*PREVENTIVE MEASURES

*RELEVANT NHP’s