DEPARTMENT OF COMMUNITY MEDICINE

RAJSHREE MEDICAL RESEARCH INSTITUTE,

BAREILLY

CLINICO-SOCIAL CASE
Supplementary Materials
INDEX

1. Socio-economic scales
a. Modified Kuppuswamy classification
b. Standard of Living Index
c. Modified B G Prasad classification
2. Urban, rural and slum
3. Types of family
4. Degree of consanguinity
5. Housing
6. Overcrowding
7. Sanitary latrine
8. Breeding habits of different mosquitoes
9. Ventilation
10. Lighting
11. Household method of purification
12. Hand washing practises
13. Sullage
14. Food taboo/myth/fad/misconceptions
15. Nutrition
16. General Examination
17. National Immunisation schedule
18. Anaemia classification
 SES SCALES

Urban Area Rural Area Can be used in both settings

 Modified  Modified B G Prasad‟ s  Standard of livingindex

Kuppuswamy‟s classification – (parasuraman etal)
scale  Udai Pareekh  BPL/APL
 Kulashreshta‟s  Wealth Index
classification  Modified B G
Prasad‟ s
classification

Modified Kuppuswamy’s Socioeconomic Status Scale

Kuppuswamy‟s Socioeconomic Status Scale1

(A) Education Score

1. Profession or Honours 7
2. Graduate or post graduate 6
3. Intermediate or post high school diploma 5
4. High school certificate 4
5. Middle school certificate 3
6. Primary school certificate 2
7. Illiterate 1

(B) Occupation Score

1. Profession 10
2. Semi-Profession 6
3. Clerical, Shop-owner, Farmer 5
4. Skilled worker 4
5. Semi-skilled worker 3
6. Unskilled worker 2
7. Unemployed 1
(C)
Score Modified:
ACPI (IW)- a = May 2022-129.2) ; b = June 2023-136.4;
Conversion factor- (b-a)x100/a )

Modified income categories = conversion factor x 2016 income (new base year) categories
Family income per Updated Monthly Updated Monthly
month(in Rs)- Family Income in INR Family Income in INR Score
original (Urban Rs (2016) Rs (June 2023)
1976)
>2000 >40430 >225276 12
1000 – 1999 20210 - 40429 112610-225275 10
750 – 999 15160 - 20209 84472-112609 6
500 – 749 10110 - 15159 56333-84471 4
300 – 499 6060 - 10109 33766-56332 3
101- 299 2021 - 6059 11256-33765 2
<100 < 2020 <11255 1

Total Score Socioeconomic class

26-29 Upper (I)
16-25 Upper Middle (II)
11-15 Middle Lower middle (III)
5-10 Lower Upper lower (IV)
<5 Lower (V)

Modified Standard Of Living Index Questionnaire

(Parasuraman et al 1999)
Type of house Pucca (1) 4
Semi-pucca (2) 2
Katcha (3) 0

Does this household own this Yes 2

house or any other house? No 0

How much agriculture land does 5 acres or more 4

this household own? 2-4.9 acres 3
< 2 acres or unknown acreage 2
No land 0

Out of this land, how much is Some 2

irrigated? None 0
Does this household own any Yes 2
livestock? No 0

Do you have a separate room Yes 1

which is used as a kitchen? No 0

What type of fuel does your Wood 0

household mainly used for Crop residues 0
cooking? Dung cakes 0
Coal/ coke/ lignite 1
Charcoal 1
Kerosene 1
Electricity 2
LPG 2
Bio-gas 2

What is the main source of Electricity 2

lighting for your household? Kerosene 1
Gas 1
Oil 1

What is the main source of PIPED WATER, piped into 2

drinking water for members of Residence/ yard/ Plot
your household? Public tank 1
GROUND WATER
Hand pump at residence/ yard/Plot 2
Public hand pump 1
WELL WATER, 2
Well in residence, yard, plot
Covered well 2
Opened well
Public well 1
Covered well 1
Opened well
SURFACE WATER 0
Spring 0
River/Stream 0
 Pond/Lake 0
Dam 0
RAIN WATER 0
TANKER TRUCK

What kind of toilet facility does FLUSH TOILET

your household have? Own flush toilet 4
Shared flush toilet 2
Public flush toilet 2
PIT TOILET/ LATRINE
Own pit toilet/ latrine 2
Shared toilet/ latrine 1
Public toilet/ latrine 1
NO FACILITY AVAILABLE 0

What kind of toilet facility does FLUSH TOILET

your household have? Own flush toilet 4
Shared flush toilet 2
Public flush toilet 2
PIT TOILET/ LATRINE
Own pit toilet/ latrine 2
Shared toilet/ latrine 1
Public toilet/ latrine 1
NO FACILITY AVAILABLE 0

Does the household own any one Yes No

of the following
A Mattress 1 0
A pressure cooker 1 0
A Chair 1 0
A Cot or Bed 1 0
A Table 1 0
A clock or watch 1 0
An electric watch 2 0
A Bicycle 2 0
A Radio/ transistor 2 0
A Sewing machine 2 0
A telephone 3 0
A Refrigerator 3 0
A Black & white television 2 0
A Colour television 3 0
A Moped, Scooter, Motor 3 0
A Car 4 0
A Water pump 2 0
A Bullock cart 2 0
A thresher 2 0
A Tractor 4 0

TOTAL SCORE

(1) Pucca: one which is built with a foundation, using stone or bricks with mortar and cement,
and having concrete or a stone laid roof
(2) Semi-pucca: one house in which some cement or mortar plastering or flooring or roofing is
used.
(3) Katcha: A construction with more than one room and using mud walls and a thatched roof
0-14: LOW 15-24: MIDDLE 25-67: HIGH

MODIFIED B G PRASAD CLASSIFICATION

Consumer Price Index for Industrial workers (CPI) ..

JUNE 2023- 136.4
I 8967 and above

II 4483 to 8966

III 2690 to 4482

IV 1046 to 2089

V 1045 and below

 What is an Urban Area?

According to the Census of India 2001, an urban area is the one which fulfils the following
criteria:
a) All statutory places with a municipality, corporation, cantonment board or notified town area
committee, etc. OR
b) A place satisfying the following three criteria simultaneously:
i. A minimum population of 5,000;
ii. At least 75 per cent of male working population engaged in non-
agricultural pursuits; and
iii. A density of population of at least 400 per sq. km. (1,000 per sq.
mile)

What is a rural area

According to the Census of India 2001, all those areas which do not fulfil the criteria for urban
area are grouped as rural areas

What is a slum?
According to the Census of India 2001, slum areas broadly constitute:
1. All specified areas in a town or city notified as „Slum‟ by State/Local Government and UT
Administration under any Act including a „Slum Act‟.
2. All areas recognized as „Slum‟ by State/Local Government and UT Administration, Housing
and Slum Boards, which may have not been formally notified as slum under any act;
3. A compact area of a population of at least 300; or about 60-70 households of poorly built
congested tenements, in unhygienic environment usually with inadequate infrastructure and
lacking in proper sanitary and drinking water facilities.

The UN habitat defines a slum as an area lacking the following facilities:

a. Access to improved water
b. Access to improved sanitation
c. Security of tenure (the right to effective protection by the state against arbitrary, unlawful
eviction)
d. Durability of housing (including living in a non - hazardous location)
e. Sufficient living area (no overcrowding).
FAMILY

It is defined as a group of individuals related biologically or by the institution of marriage living

together and eating from the same kitchen.
Q. What is a nuclear family / elementary family?

A nuclear family is the one which consists of married couple living with their children while the
children are still regarded as dependent on the couple.
i. They share a common dwelling place
ii. Husband plays a dominant role usually
iii. Greater burden in terms of responsibilities for child rearing.
iv. More intimate relationship between husband and wife
v. „New‟ families are the nuclear families that are less than 10
years old

Q. What is a joint family/extended family?

A joint family is the one where in a number of married couples and their children live together
live in the same house. The men are all related by blood and the women are their wives,
unmarried girls and widows of their family kinsmen
i. The property is held in common. There is a common purse to which all the money goes
and the family expenditure is met with by that common purse
ii. The most senior male member is the head of family and takes all the decisions. His wife is
the head of the women folk in the family.
iii. Familial relations enjoy primacy over marital relations.

Q. What is a three generation family?

It is a family where representatives of three generation are living together.

Young married couples continue to stay with their parents and have their own children as well.
 i. This is fairly common in countries like India where married couples find it difficult to
find separate accommodation.
ii. It has some of the advantages of the joint family with regards to the responsibility in
upbringing of the children
iii. In urban areas with working women it has more relevance; the grand parents can
take care of children in the absence of their parents.
iv. Also, senior citizens of the family stay with the young couple; they are also taken
care of, thereby supporting them.

What are the various degrees of consanguinity?

Four degrees of consanguinity have been identified.

1st degree = Marriage between siblings (Incest)
2nd degree = Marriage between uncle and niece (girl marrying her mother‟s brother)
3rd degree = Marriage between first cousins (girl marrying her uncle‟s son)
4th degree = Marriage between second cousins or between people with a relationship beyond
second cousins or a far off relationship all fall under this category.

HOUSING DEFINITIONS

PUCCA HOUSE:
Floor, roof and wall are made of impervious material
A pucca house is long lasting and does not allow rain water, insects, snakes etc…to come into
the house. It gives good shelter to the inmates. It protects against cold, heat, and dampness.

Wall Roof

· Burnt bricks · Tiles

· Stones · G.I/Metal
· Concrete · Asbestos
· Cement · Concrete
· Timber · Bricks
· Stone
· Timber
KUTCHA HOUSE
Any one of Floor, roof and wall made of pervious material
· Un burnt bricks
· Bamboos
· Mud
· Grass
· Reeds
· Thatch
· Loosely packed stone

OVERCROWDING CRITERIA

 Persons per room criteria- >2 person per room

 Per capita floor space- < 50 sq feet/person
 Sex separation - Overcrowding is considered to exist if 2 persons over 9 years of age, not
husband and wife, of opposite sexes are obliged to sleep in the same room.

BABY UNDER 12 MONTHS NOT COUNTED, CHILDREN 1-10 YEARS CONSIDERED

ASHALF IN CASE OF MEASUREMENT

SANITARY LATRINE

To tell a latrine to be sanitary

 Presence of water seal- Prevents odour from escaping and prevent breeding of flies&
insects
 Connected to a distribution system/ septic tank- Prevent pollution of water and soil in
the surrounding area

BREEDING HABITS OF MOSQUITOES

 Anopheles- fresh flowing water

 Aedes- Artificial collections of water
 Culex- Dirty stagnant water
 Mansonia- Under the leaves of aquatic plants

VENTILATION

 Door + window space should be more than 2/5th of the floor space area
 Window space should be > 1/5th (urban) /1/10th (rural) of the floor space area
 LIGHTING
 In the four corners of the room and in the centre of the room if you can read newspaper or
pick stones from rice or sew a needle in natural light then lighting is adequate

HOUSEHOLD METHODS OF WATER PURIFICATION

 Boiling
 Chlorine tablet- single tablet 0.5gm/20 litre of water
 Iodine tablet- two drops of % ethanol solution of Iodine
 Filters
 RO (Reverse osmosis) filters
 Bleaching powder
 Potassium permanganate
 Storage
 Sieving

HAND WASHING PRACTISES

With soap and water - adequate

 Before and after eating

 After defecation
 Before feeding a child
 After washing the bottom of the child

SULLAGE

 Waste water without human excreta

FOOD TABOO/FADS/MYTHS/MISCONCEPTIONS

 Food fad- A like or dislike of a particular food taken to extreme

Eg. Paleo diet
 Food taboos- rules or codified laws about foods or combination of
foods e.g Islam- eating pig; Hindus- eating cows
 Food myth – legendary story concerning food connected to a hero or an event with
orwithout fact
 e.g Eating particular food – make baby fair
 Food misconceptions- review or opinion that is incorrect.
Vegetarian diet- protein deficient

NUTRITION

Oil usage adequate- 1/2 liter per person per month

Salt usage – 5 gm per day per person

ENERGY REQUIREMENT PROTEIN

(K cal) ICMR 2020 REQUIREMENT
ICMR 2020

Adult male
Sedentary 2110
Moderate 2710 0.83 gm per kg
Heavy 3470

Adult female
Sedentary 1660 0.83 gm per kg
Moderate 2130
Heavy 2720

Children
Infants 100 kcal/kg 1.5-2 gm/kg
1-5 years 79 kcal/kg 0.95 gm/kg
6-10 years 68 kcal/kg 0.91 gm/kg
11-18 years male 56 kcal/kg 0.88 gm/kg
11-18 years female 51 kcal/kg 0.86gm/kg

Pregnancy additional + 350 + 9.5 gm & 22 gm in 2nd &

3rd trimester resp.

Lactation additional
· First 6 months + 600 + 17gm
· Next 6 months + 520 + 13gm
GENERAL EXAMINATION

Female Male

Waist circumference normal <88 cm <102cm

Waist Hip ratio normal <0.85 <1

HOW TO CALCULATE WEIGHT OF THE BABY BASED ON AGE

Weech‟s formula
Expected weight in Kg

★ · Up to one year- age (months)+ 9

2
★
★ · 1-6 years - age (years) ×2+8
★
★ · 6-12 years- age(years) × 7- 5
2
Expected height up to 12 year

★ · Height in cm – age in years × 6 + 77

IAP Classification for weight for age

Waterlow classification for height for age

MID ARM CIRCUMFERENCE

For children from 1-5 years

Normal ≥ 13.5 cm

Mild malnourishment 12.5- 13.49 cm

At risk 11.5- 12.49 cm

Severe <11.5 cm
NATIONAL IMMUNISATION SCHEDULE

Vaccine When to give Dose Route Site

At birth

Hepatitis B At birth or as early Antero-lateral

as possible within 0.5 ml Intra - muscular side of mid-
24 hours thigh

bOPV - 0 At birth or as early 2 drops Oral Oral

as possible within
the first 15 days

BCG At birth or as early 0.1 ml (0.05 ml Intra - dermal Left upper arm
as possible till one until one month
year of age age)

At 6, 10 and 14 weeks

OPV 1,2 & 3 At 6weeks, 10

weeks and 14 2 drops Oral Oral
weeks

Pentavalent 1,2 and 3 At 6 weeks, 10 0.5 ml Intra - muscular Antero-lateral

(DPT-Hep B-HiB) weeks and 14 side of mid thigh
weeks

IPV 1 and 2 Two fractional 0.1 ml Intra-dermal Antero-lateral

doses at 6 weeks side of mid thigh
and 14weeks
Pneumococcal At 6 & 14 weeks 0.5 ml Inra-muscular Antero-lateral
side of mid thigh

Rota virus At 6 weeks, 10 weeks

& 14 week 5 drops oral
At 9 months
Measles Rubella 9 completed months 0.5 ml sub cutaneous Right
upper arm

JE vaccine 9 -12 months 0.5ml Su-cutaneous Left Upper arm

Vitamin A - 1 9 completed months 1 ml 1 lakh IU oral

At 16- 24 months (1 ½ years)

DPT booster-1 16- 24 months 0.5 ml Intra -muscular Antero-lateral

side of mid thigh

OPV booster 16- 24 months 2 drops Oral Oral

Measles
Rubella-2 16 –9 24
completed
months months
0.5 ml0.5 ml Sub-cutaneous
sub cutaneous Right
RightUpper Arm
upper arm
JE Vaccine-2 9 completed months 0.5 ml sub cutaneous Right
16 – 24 months 0.5 ml Sub-cutaneous Left Upper
upper arm Arm

DPT Booster-2 5 – 6 years 0.5 ml Intra - muscular Upper Arm

TT/Td 10 years and 16 years 0.5 ml Intra - muscular Upper Arm

For pregnant women

TT-1 Early in pregnancy 0.5 ml Intra - muscular Upper Arm

TT-2 4 weeks after TT -1 0.5 ml Intra - muscular Upper Arm

TT/Td - Booster If received 2TT doses in 0.5 ml Intra - muscular Upper Arm
a pregnancy within last
3 years

ANAEMIA CLASSIFICATION

Population Non anaemic mild moderate severe

6m-5 years >11 10-10.9 7-9.9 <7

Pregnant women >11 10-10.9 7-9.9 <7

5-11 years >11.5 11-11.4 8-10.9 <8

12-14 years >12 11-111.9 8-10.9 <8

Non Pregnant >12 11-11.9 8-10.9 <8

women

Men 15 years >13 11-12.9 8-10.9 <8

and above
CASE DISCUSSION
ANTENATAL CASE

Recommendations

Individual level

1. Counsel the mother on all elements of Essential Obstetric Care

· Early registration of pregnancy, MCP card
· At least 4 ANC visits
· 2 TT (or 1 booster)
· Minimum of 100 IFA tablets after 12 weeks, Daily supplementation with Calcium 1000mg
and Deworming with single dose Albendazole 400 mg preferably in the second trimester of
pregnancy
· Screening for high risk during pregnancy (by history, on examination, thru lab
investigations)
· Institutional Delivery with skilled birth attendance

2. Counsel the mother on Birth Preparedness and Complication readiness

· Awareness regarding danger signs during pregnancy, delivery and postpartum (Fever,
Persistent vomiting, Palpitations, Breathlessness at rest/on mild exertion, Generalised swelling
of the body, puffiness of the face, Severe headache and blurring of vision, convulsions, Passing
smaller amounts of urine and burning sensation during micturition, Vaginal bleeding, Decreased
or absent foetal movement, foul smelling vaginal discharge)
· Identify and arrange emergency transport
· Identify and arrange blood donor
· Identify institution for delivery
· Keep aside money for the delivery
3. Diet
· add calorie-rich healthy snacks
· consume more proteins - pulses, dhal, milk, egg, non-veg
· increase fibre, vitamins and minerals – fruits and vegetables
· increase iron intake – ragi, red meats, fruits, green leafy vegetables
· increase calcium intake - milk, curds, ragi
· address any food fads and food taboos
4. Supplements
· Iron and folic acid tablets – 100 mg of elemental iron (335mg ferrous sulphate) and 500ug
folic acid, one tablet every day for at least 100 days. Preferably to be taken with a citrus fruit or
juice. Not to be taken on an empty stomach. May cause mild abdominal discomfort and
blackening of stools.
· Calcium – 1000mg per day
5. Rest
· At least 2 hours of rest in the afternoon and 8 hours of sleep at night
· Avoid lifting heavy weights
· Can continue light housewo

6. What to avoid
· Smoking, and passive smoking
· Alcohol
· Drugs unless prescribed by a doctor
· Radiation- X-Rays, CT etc.
7. Breast feeding counselling - Focus on early initiation, dangers of pre-lacteal feeds,
exclusive breastfeeding
8. Family planning advice- offer options for both spacing and terminal methods
9. Give information on various Maternity Benefit Schemes
· Janani Suraksha Yojna
· Janani Shishu Suraksha Karyakram
· IGMSY,PMSMA
· Vande Mataram scheme
· 108 ambulance
Muthulakshmi scheme

Family Level
· To create awareness among the family members regarding all components of birth
preparedness, including danger signs.
· Any harmful traditional beliefs and taboos should be addressed.
· Advice to family members on emotional support to the antenatal women, ensuring
adequate rest and nutrition, making sure essential antenatal care is received.
Community level
Target group – Adolescent and women in reproductive age group
· Advice regarding all the elements of essential antenatal care
· Importance of institutional delivery
· Importance of contraceptive use and benefits of adequate spacing for childbirth
· Advice regarding proper breast feeding practices
· Importance of immunization among the children
· Educate regarding the available maternal health benefit schemes like Janani suraksh
ayojana, Janani shishu suraksha karyakram etc.
· Importance of taking iron and folic acid tablets
Viva Questions

1. How do you confirm pregnancy?

2. What is Essential antenatal care?
3. What is preterm, term and post term delivery?
4. What are the danger signs in pregnancy?
5. What are the warning signs of impending labour?
6. What is Risk approach? Give examples of high risk pregnancy?
7. How do you screen for high risk in pregnancy? (through history…examination..
investigations)
8. Define Gravidity, Parity, Abortion, Stillbirth, Maternal death
Gravida- number of pregnancies including the present
Para- Number of pregnancies which have crossed the period of viability ( 28 weeks)
9. What is the current Maternal mortality rate? What are the common causes of maternal
mortality in India?
10. What are the measures to improve maternal nutritional status (direct and indirect)?
11. What is the content and dose of iron and folic acid given to antenatal women?
12. What advice will you give while prescribing iron and folic acid tablets in antenatal women?
13. How many doses of TT should a pregnant mother receive and when? What is the purpose of
giving TT immunization?
14. What is the weight gain range considered to be normal for pregnant women?
15. Define and classify anaemia in pregnancy? What are the causes of anaemia in pregnancy?
16. How do you manage anaemia in pregnancy?
17. Who is an ASHA and what role does she play during the delivery?
18. How do you prevent infection at the place of delivery? ( 5Cs, handwashing with soap and
water, use of sterile gloves, Daily cleaning of delivery room surfaces with 2% carbolic acid,
wiping of electronic equipment with 70% alcohol, sterilization of instruments, decontaminate,
clean, sterilize, store), safe handling and disposal of sharps and appropriate biomedical waste
management.)
19. What is MCTS? What is MCP card ?
20. What is an FRU? What facilities are available at an FRU?
21. Name maternity benefit schemes available for pregnant mothers during pregnancy and after
delivery?
POSTNATAL CASE

Recommendations
Individual Level

For the Mother:

1. Awareness regarding danger signs during the postpartum period
· excessive bleeding
· fever
· foul-smelling lochia
· burning micturition
· pain and swelling in the breasts
· convulsions
· calf tenderness

2. Four Post natal visits on 1, 3,7,42 days of delivery

3. Diet
· Increase calorie intake by consuming at least 2 extra meals
· consume more proteins - pulses, dhal, milk, egg, non-veg
· increase iron intake – ragi, red meats, fruits, green leafy vegetables
· increase calcium intake - milk, curds, ragi
· address any food fads and food taboos
· drink plenty of water

4. Nutritional Supplements
· Iron and folic acid – 100 mg elemental iron daily for 100 days in the postpartum
period
· Calcium – 1000mg daily for 6 months after delivery

5. If episiotomy has been given

· perineal toileting
· warm sitz bath
· diclofenac suppositories for pain relief
6. Personal Hygiene
· daily bath
· handwashing
· perineal toileting
· no need to wash breasts before breastfeeding

7. Physical Activity
· Importance of rest
· avoid lifting heavy weights
· do simple pelvic floor exercises
· resume sexual relations only after 6 weeks

8. Family Planning
· Information regarding the various family planning methods available
· IUD or condom as a spacing method
· male or female sterilisation in case the family is complete

9. Mother-Craft
· Enabling mothers to take care of their infants – focus on breastfeeding,
complementary feeds, food recipes for infants, care of the baby during illness

For the Baby

1. Awareness regarding danger signs in the newborn

· Fever / hypothermia
· Lethargic / difficult to awake
· Difficult / fast breathing
· Yellow discoloration over palms and soles
· Poor sucking / feeding
· Convulsions / Rigidity
· Pus / redness of umbilicus

2. Prevent hypothermia
· Keep the baby warm
· Immediate drying
· Covering the head
· Skin to skin care (Kangaroo Mother Care)
· Delaying first bath
· Rooming-in/ Bedding-in

3. Prevent infection
· Care of the cord
· Care of the eyes
· Hand washing before handling the baby
· Kangaroo mother care
· Avoid too many visitors handling the baby
4. Six Checkups for the baby (includes home-visit by ANM/ASHA) on Day 3,7,14,21,
28,42.
5. Breast feeding
· Early initiation
· No pre lacteal feeds
· Exclusive breastfeeding for the first 6 months
· Breastfeeding on demand
· Proper positioning and attachment
· Complementary feeds at 6 months
· Continue breastfeeding for at least 2 years
6. Immunisation
· At Birth - Hepatitis B vaccine –birth dose
· oral polio vaccine
· BCG
· Maintain immunisation card carefully
Family level
· Encourage the family to support the mother – emotionally (watch out for signs of
depression), in the care of the baby, adequate nutrition for the mother, postnatal visits
· Birth Registration for the infant
· Hand washing, including before handling the baby
· Address any food taboos and harmful cultural practices
· Awareness regarding the schemes availed from the government like supplementary
nutrition at the Anganwadi, Janani Shishu Suraksha Karyakram
Community Level
Improving awareness in the community regarding
· Nutrition for postnatal mothers
· Infant and young child feeding practices
· Immunization
· Maternity and infant benefit schemes
· Family planning
Viva Questions
1. Define postpartum period, perinatal and neonatal period.
2. How many post natal visits are recommended? And when? (Days 1,3,7 and 42. For home
based newborn care visit by ASHA on days 3,7,14,21,28,42)
3. What is the normal involution pattern of uterus after delivery?
4. What are the complications in the postnatal period?
5. What are the symptoms or signs of puerperal sepsis?
6. What advice will you give to a postnatal mother? (Danger signs, visits, diet, exercise, IFA
tablets, personal hygiene, breastfeeding, family planning, care of the newborn)
7. When can IUD be inserted in the post partum period (PPIUCD within 10 mins of delivery
of placenta or during LSCS after removal of placenta, or within 48 hours of delivery. It can also
be inserted at 6 weeks postpartum)
8. What is the extra nutrition required by a lactating mother?
9. What are the preferred methods of contraception after the birth of a child?
10. What do you understand by APGAR score?
11. What is the first milk called? What is its importance?
12. What is exclusive breast feeding? For how long should breast feeding be continued?
13. What are the advantages of breast feeding?
14. What is good positioning and good attachment?
15. What is rooming in?
16. What is baby friendly hospital initiative?
17. When should complementary feeding begin? What are the ideal complementary foods?
18. What are the normal birth weight, height, and head circumference of a child?
19. Who is an at-risk infant?
20. What is kangaroo mother care and what is its advantage?
21. What is Ushers criteria? Criteria to assess prematurity
22. What are the danger signs in a newborn?
23. What are main causes of infant mortality?
24. List some socio-cultural practices that are followed commonly during postpartum period
(harmful practices to avoid, beneficial practices to be encouraged)
25. What is Low birth weight? What are the common causes of LBW?
26. What are the vaccines given to a newborn?
27. What is Essential Newborn Care? (Draught –free NBCC with radiant warmer with neonatal
mask and bag, Resuscitation, Warmth, Early initiation of breastfeeding, Weighing the baby,
Inspection for gross anomalies, Identify and refer at-risk or sick newborns, Cord care,
Immunization.
DIABETES CASE

Recommendations

Individual Level

1. Relief of symptoms
· If the patient‟s blood sugar is under control, ask to continue the same medicines. If not,
record the blood sugar and adjust medication.
· If the patient has any other symptoms, treat accordingly (Eg: paraesthesia, wound, etc.)
· If the patient has any comorbidities (hypertension etc), treat accordingly and keep in mind
drug interactions.

2. Diet
· Consume foods with a low glycaemic index (avoid sweets, white bread/rice, potato)
· Whole grain cereals preferred, Keeping staple diet of patient in mind
· Fruits with edible skin preferred to fruit juices.
· Eat small quantities at frequent intervals.
· Reduce the consumption of oil and its forms in cooking
· Reduction of fried foods and bakery products.
· Aim for 5 servings of vegetables and fruits per day.
· Avoid Alcohol – concept of empty calories
· “NO fasting, NO feasting”.

3. Exercise
· Advice based on BMI of patient – weight loss/wt. maintenance. Reduce the weight on
basis of normal BMI calculation or nearer to height in cms-100 or
· Aerobic exercises like walking, cycling, and swimming
· Start slow and for short time –gradually increase to a brisk pace, reaching target of 30 – 45
mins per day for most days of the week.
· Precautions to be taken while exercising – Walk early morning to avoid harsh sun, avoid
darkness to prevent any falls/accidents. Walk on a flat surface wearing comfortable footwear.
· Other types of exercise – body building like weight lifting, yoga, meditation for stress
relief, upper body exercises in case of knee pain

4. Self-care
· Personal hygiene – daily bath, clean clothes, trim nails
· Avoid injuries. Immediate care in case of any wound.
· Foot Care: Examine the feet every day for any injuries, cracks, swellings, callosity,
redness or increased temperature or ingrown nail or loss of sensation. Keep feet and interdigital
space dry by using towel/dusting powder if necessary. Use of mirror in examination of the feet.

5. Adherence to Medications
· To take timely and adequately
· Not to change dosage without doctor‟s advice
· If on insulin, correctly follow the procedure and dosage.

6. General Information
· About symptoms of hypoglycaemia (sweating, giddiness, headache, fainting), glycosuria
and complications of the disease.
· Carry sweets with the patient in case of emergency.
· Carry a card with details of the patient-name, address, phone number, about disease and
prescribed medicines.
· To avoid tobacco usage in any form.

7. Monitoring Diabetes with Lab Investigations

· Home glucose monitoring as often as necessary, at least weekly
Every day- foot examination
· Every month: fasting and postprandial blood sugar ( should be modified depending on
control), BP measurement, Weight measurement
· Every 3 months: HbA1C
Every 6 months - HbA1C , If sugar levels are controlled
· Every year: ECG, lipid profile, Serum creatinine, urine microalbuminuria, Fundus
examination

Family Level

· Importance of diet, exercise and proper follow up in controlling blood sugar and
preventing further complications.
· Importance of diet monitoring as it is better to avoid more sweet and oily foods in the diet
of the patient.
· Screening to be done for other family members.
Community Level
Health education
· To target the high risk groups:
· People over the age of 45 years, obese people, with family history of diabetes mellitus,
history of gestational diabetes, pre diabetics, hypertensive patients, female with baby weighing
more than 3.5 kg, females with excess weight gain in pregnancy
· Life style modifications, including primordial prevention among adolescents
· Importance of adherence to medications, diet, exercise and foot care.
· Knowledge regarding the Symptoms and Complications of Diabetes

Viva Questions

1. What is diabetes mellitus?

2. What is the classification of diabetes mellitus?
3. What is impaired glucose tolerance?
4. What is impaired fasting glucose?
5. What is syndrome X?
6. What are the screening tests used for diabetes mellitus?
7. What is HbA1C?
8. What are the complications of diabetes mellitus?
9. What are the common oral hypoglycaemic agents?
10. What are the host factors that lead to diabetes mellitus?
11. What are the environmental factors that lead to diabetes mellitus?
12. What is primordial prevention? Whether it is applicable to hypertension?
13. What is primary prevention? Whether it is applicable to hypertension?
14. What is secondary prevention? Whether it is applicable to hypertension?
15. Which are the high risk groups for screening diabetes mellitus?
16. Why insulin is used as a treatment for diabetes mellitus?
17. What are the treatment available for gestational diabetes mellitus
18. Why foot care is important in diabetes mellitus
19. List one side effect each for oral hypoglycaemic
20. What is glycaemic index. Give examples.
21. Name few foods that should be eaten/avoided in a diabetic
HYPERTENSION CASE

Recommendations
Individual Level
1. Relief of symptoms
· If the patient‟s blood pressure is under control, ask to continue the same medicines. If not,
record the blood pressure and adjust the tablets.
· If the patient has any comorbidities (diabetes etc), treat accordingly and keep in mind drug
interactions.
2. Diet
· DASH therapy (Dietary Approaches to Stop Hypertension) - diet rich in fibre, whole grain
cereals, fruits and vegetables and low in dairy products, fried foods, saturated and transfats.
· Intake of salt to not more than 5 g/day (Avoid eating salty foods like papad, pickles etc,
avoid sprinkling extra salt over food)
· Avoidance of alcohol and smoking

3. Exercise
· Do brisk walking for at least 30-40 min per day- till you sweat. Start it slowly and sustain
it for most of the days.
· Avoid stress and practice any of the stress relieving practices like meditation, listening to
music, dance, etc.
· Other forms of exercise.
· Reduce the weight on basis of normal BMI calculation or nearer to height in cms-100.
4. Investigations
· Once a month get the BP recorded, or Home BP monitoring as often as necessary
· Once yearly do kidney function test, liver function test, ECG, lipid profile, eye check-up
and fundus examination,
5. Other advise
· Ask the patient to be adherent to medications
· Should take medications as prescribed by the doctor
· Routine monthly check up with a physician
· If there is any severe headache, pedal edema, oliguria please consult the doctor
Family Level

· Family members to motivate the patient for adherence to medications and take the patient
for regular check up.
· Prepare food which has less salt and then add salt for others later
· Importance of diet, exercise and proper follow up in controlling blood pressure and
preventing further complications.
· Screening to be done for other family members.
· To avoid alcohol and tobacco usage.
Community Level
· Screening for high risk groups
· People over the age of 45years, obese people, with family history of hypertension,
cardiovascular diseases, stroke, kidney diseases etc.
·
· Health education
· Importance of adherence to proper diet, exercise
· Symptoms of high blood pressure
· Complications of hypertension like stroke, hypertensive retinopathy, nephropathy,
cardiovascular diseases and the need for adherence to medication and routine check up
Viva Questions

1. What is the value of blood pressure to be called hypertension?

2. What is the classification for hypertension? What is JNC
3. Differences between JNC 7 and 8
4. What are the complications of hypertension?
5. What is essential hypertension?
6. What is secondary hypertension and give examples?
7. Explain rule of halves.
8. Explain the tracking of blood pressure.
9. What are the non-modifiable risk factors in hypertension?
10. What are the modifiable risk factors in hypertension?
11. What is primordial prevention? Whether it is applicable to hypertension?
12. What is primary prevention? Whether it is applicable to hypertension?
13. What is secondary prevention? Whether it is applicable to hypertension?
14. What is Non-pharmacological approach for hypertension
15. What are the common drugs available for the treatment of hypertension?
16. Which is the first line drug used for a patient if he is diabetic and hypertensive?
17. What is syndrome X or metabolic syndrome?
18. What is the common risk factor approach for hypertension?
19. What are the dietary approaches for the treatment for hypertension? What is DASH therapy?
ACUTE RESPIRATORY INFECTIONS (A.R.I) CASE

Recommendations
Individual level
1. Relief of symptoms
· Treatment depends on age of the child, classification of illness according to WHO
standard case management for ARI
· Antibiotics, if needed, according to the age and weight
· Treat fever - Syrup Paracetamol 10-15mg/kg body weight/dose
· Treatment of wheezing
· Treat any ear infection
· Home remedies for cough
· Reassurance
· Ask the mother to return if the child gets worse or develops any danger signs (fast
breathing, chest in drawing, convulsions, fever, difficult to wake, stops feeding)
· To come for follow up after 2 days.
2. Nutrition
· Increase fluid intake
· Continue feeding during illness
· An extra meal a day for a month after the child recovers for catch up growth
3. Advice regarding personal hygiene, hand washing.
4. Immunization
· Pentavalent vaccine (Diphtheria, Pertussis, H.Influenza B)
· Measles vaccine
· Vitamin A
· Pneumococcal vaccine (optional)
Family and Community Level
· Education regarding prevention of ARI
· Avoiding indoor air pollution – kitchen smoke, passive smoking, aerosol sprays,
agarbhatti, dhoomp/sambrani
· Handwashing
· Breast feeding: promotion of exclusive breast feeding for the first 6 months, discourage
bottle feeds or formula feeds
· Immunisation
· Vit A supplementation
· Nutrition
· Benefits of attending the anganwadi
Viva Questions
1. What are the 5 commonest childhood killer diseases?
2. (ARI, Diarrhoea, Measles, Malaria, Malnutrition)
3. How do you define Acute Respiratory Infection?
4. What are the causes of ARI among children (medical causes and socio-cultural factors)
5. How do you classify ARI in a child aged 2 months to 5 years?
6. How do you classify ARI in a young infant aged less than 2 months?
7. How do you assess for fast breathing? What are the respiratory rate cut-offs?
8. How do you assess a child for chest in-drawing?
9. Why is the category of “pneumonia” missing in the classification for a young infant aged
less than 2 months?
10. What are the signs of very severe disease? Why is it termed as such, and not as very severe
pneumonia?
11. What is the antibiotic of choice for pneumonia according to the WHO standard case
management? State the doses according to age/weight.
12. What are the antibiotics of choice for treatment of pneumonia in a child aged less than 2
months?
13. What are the various vaccines available to prevent respiratory illnesses among children?
14. How do you define fever in a child? (axillary temp >37.5 C, rectal temp cut-offs are 0.5 C
higher)
15. How do you define hypothermia in a child? (axillary temp<35.5 C, rectal temp cut-offs are
0.5 C higher)
16. How can a mother handle fever in a child at home before approaching health facility?
17. What is the recommended dose of Paracetamol in children?
18. What are the common differential diagnoses for fever in a Child? (Cough-cold, pneumonia,
ear infections, dysentery, malaria, dengue, measles, viral fever, skin infections)
19. What are the differential diagnoses of fever with rash in children? (measles, chicken pox,
rubella, dengue, chikungunya, rheumatic fever, meningitis, leptospirosis, rickettsial ds, drug-
hypersensitivity)
20. According to IMNCI, what are the signs to check for in a young infant (less than 2 months)
to rule out possible bacterial infection? (lethargy, unconscious, convulsions, fast breathing,
severe chest indrawing, nasal flaring, grunting, bulging anterior fontanelle, skin pustules,
umbilicus red or draining pus, icterus over palms and soles)
21. What are the commonest complications of measles? (pneumonia, diarrhoea, ear infection,
eye infection, malnutrition)
22. State the National Immunisation schedule.
23. What are the leading causes of death among children?
DIARRHOEA CASE

Recommendations
Individual Level

1. Relief of symptoms
· Fever: Syrup Paracetamol 10-15mg/kg body weight/dose Q6H, tepid sponging

2. Management of Dehydration
· No dehydration (Plan A): Give the child home available fluids (rice water, kanji,
unsalted soup, water in which cereal has been cooked, yogurt drinks, green coconut
water). Avoid commercial carbonated beverages/ fruit juices and hot beverages like
tea/coffee. Continue breast feeding and keep the child warm. Give the mother a packet
of ORS and show her how to prepare and give to the child. Return if the child‟s
condition worsens.

· Some dehydration (Plan B): ORS solution @ 75ml/kg body weight in the first 4 hours
and reassess for signs of dehydration. Older children should be given as much water as
they want in addition to ORS.

· Severe dehydration (Plan C): Child is referred to a higher centre where intravenous
fluid rehydration is available. Ringers‟ lactate solution or Diarrhoea Treatment Solution
is given according to the following treatment plan. Reassess the child every 1-2 hours.

Age First give 30ml/kg in Then give 70ml/kg in

Infants 1 hour 5 hours

Older 30 minutes 2.5 hours

Once severe dehydration is corrected, ORS should be given for maintenance therapy.
· Return in case of danger signs (not able to drink/ abnormally sleepy or difficult to wake/
convulsions/ stridor in calm/ severe malnutrition) or if child‟s diarrhoea worsens

3. Diet
· Give easy to digest, non-spicy diet.
· Drink lots of liquids/water
· Continue breast feeding
· An extra meal a day for a month after the child recovers for catch up growth
4. Nutritional Supplements
· Zinc Syrup Zinc – 10mg (< 6 months) / 20mg (>6 months) once a day, for a duration
of 10-14 days
· Vitamin A supplementation – 50,000IU/ 1,00,000 IU/ 2,00,000 IU depending on the
age of the child.

5. If any danger signs: (not able to drink, abnormally sleepy or difficult to wake,
convulsions, difficult breathing stridor in calm/ severe malnutrition) are present, give first dose
of antibiotic and refer to higher centre.

6. In case of persistent diarrhoea

· stool routine/microscopy and stool culture,
· Blood culture
· Widal test

7. Immunisation
· especially Measles and Rotavirus vaccine
· Rotarix: 2 doses, 4 weeks apart, should be given between 2-4 months of age /
RotaTeq: 3 doses @ 2,4,6 months of age)
· Measles – at 9th month and 18th month according to National Immunization
Schedule (0.5ml, sub cutaneous)

8. Sanitation
· Use a Sanitary latrine
· Consumption of safe drinking water (household level of water purification)
· Adequate hand washing practices

Family and Community level

· Use of ORS and Home Available Fluids during diarrhoea

· Continue feeds during diarrhoea
· Adequate hand washing practices (hand washing with soap before preparing food, before
eating, before feeding a child, after defaecation, after cleaning a child‟s bottom and after
disposing a child‟s stools)
· Sanitation: use of sanitary latrine, proper disposal of child‟s stools and avoid
indiscriminate open air defaecation Proper solid waste disposal
· Safe water: promote household methods of purification of water (storage/ filter/ roll
boiling/ UV-RO/ halazone tablets)
· Food hygiene: avoid foods from outside, give freshly hygienically prepared homemade
food, protect food from flies by storing in containers or covering the food
· Breast feeding: promotion of exclusive breast feeding for the first 6 months, discourage
bottle feeds or formula feeds
· Complementary feeding: Initiate complementary feeding at six months with nutritious,
locally available foods, continue breast feeding
· Immunization especially Measles, Vitamin A and Rotavirus

Viva Questions

1. What is diarrhoea ?
2. How is diarrhoeal disease classified by WHO?
3. What causes diarrhoea in children? (medical causes and sociocultural factors)
4. How many episodes of diarrhoea does a child under 5 years usually in a year?
5. What are the constituents of ORS?
6. What are the 3 star signs or key signs of dehydration?
7. What are the 3 categories of dehydration according to WHO?
8. What is main component of each of the WHO treatment Plans A ,B and C?
9. List the various home available fluids?
10. How much ORS should be given to a child with some dehydration?
11. Which are the IV fluids that can be given to a child with severe dehydration ? What is the
recommended dose of IV fluids?
12. Which micronutrients are important in the prevention (Vit A) and treatment (Zinc) of
diarrhoea and Why? What is the dose to be given?
13. What is the role of antibiotics in the management of diarrhoea?
14. What do you understand by sanitation barrier?
15. What are primary level preventive measures for diarrhoea?
16. What instructions will you give to the mother regarding preparation of ORS?
17. Rotavirus vaccine – types / dosage / route of administration / schedule.
TUBERCULOSIS CASE

Recommendations

Individual level

1. Relief of symptoms
· Relief of fever using antipyretics
· Relief of painful nodes using analgesics

2. Confirm the diagnosis

· Confirmation of diagnosis in a DMC using two smear microscopy for acid fast bacilli
· Chest XRay (as per diagnostic algorithm)
· Mantoux test in children
· CBNAAT – Cartridge based Nucleic acid Amplification Test, especially for children and
PLHIV
· FNAC, Histopathology for extra-pulmonary TB
· Drug-sensitivity testing (Rapid molecular or culture) for those starting on Cat II, for HIV-
TB and for those who remain sputum positive during Cat I regimen.

3. HIV testing and counselling

4. Rule out pregnancy in a female patient

5. Registration
· Registration under NIKSHAY
· Obtainment of treatment card and identify a DOTS provider
· Provision of mobile number to DOTS provider and Health worker for SMS alerts from
NIKSHAY

6. Treatment
· To follow treatment regimens under DOTS
· Determination of category of treatment as per the history and lab findings
· Patient –wise Boxes as per the category:
Now following daily regimen with fixed dose combination
 Category Box Color Regimen

I (Red box) 2 (HRZE)7 + 4

(HRE)7

II (Blue Box) 2 (HRZES)7 +

1(HRZE)7 +
5 (HRE)7

· Paediatric TB and HIV-TB must receive daily supervised treatment

· Repeat sputum test at the end of intensive phase and on completion of treatment
· Direct observed treatment – swallowing of drugs in the presence of DOTS provider or
health worker. Every dose during the intensive phase and once a week during continuation phase,
while also returning the empty blister-packs.

7. Laboratory Investigations to monitor side-effects of drugs

· Complete blood count
· Liver function test
· Renal function tests

8. Counselling
· Regarding curability, communicability, compliance to medications, follow-up
· Sanitary disposal of sputum
· Cough etiquette to be practised
· Adequate nutrition
· Abstinence from alcohol to ensure compliance

9. Disability Limitation
· Ensure compliance and completion of treatment to prevent respiratory disabilities
· Surgical intervention in cases of pneumothorax and pleural effusion
· Monitoring for drug toxicities
· Chest physiotherapy
· Vocational and social rehabilitation

Family Level

· Education regarding the nature of illness, curability, duration of treatment, adverse effects
and modes of transmission
· Psychosocial support, support for ensuring medications, follow-up
· Contact screening using sputum smear microscopy for adults with symptoms suggestive of
TB
· Contact screening for children using Mantoux and GJ AFB
· INH prophylaxis for children <6 years age for at least 6 months duration
· Ensure Sanitary disposal of sputum by either burning or burying in ground
Community Level
· Education regarding the illness its modes of transmission, treatment available and
curability
· Campaigns regarding the signs and symptoms of the illness to ensure early self-reporting
· Removing stigma by ensuring community participation and public awareness campaigns
· Strengthen utilization of routine immunization services

Viva Questions

1. What is the Case definition of Tuberculosis (TB)?

2. What is the prevalence and incidence of tuberculosis?
3. What is the difference between prevalence of TB infection and prevalence of TB disease?
4. What do you understand by new case, relapse, failure and default in the context of
Tuberculosis?
5. What are the modes of transmission of TB?
6. What are the various environmental factors that favour the transmission of TB?
7. What is the protocol for collection of sputum sample in case of TB?
8. How will you perform Ziehl-Neelson stain?
9. How will you perform and interpret Mantoux test?
10. What is the treatment schedule for TB under DOTS (Directly Observed Treatment, Short
Course Chemotherapy)?
11. What are the adverse reactions of drugs used in the treatment of TB?
12. When will you call a TB strain Multi drug resistant and extensively drug resistant?
13. Which drugs are used in the treatment of MDR (Multi Drug Resistant) TB?
14. What is the dosage and route of administration of BCG vaccine?
15. What is the diluent used to reconstitute BCG vaccine?
16. What are the objectives of the RNTCP?
17. What are the main strategies under DOTS?
18. How do you diagnose TB in children?
19. What are the categories of treatment under RNTCP and the treatment regimens?
20. List the targets under the “Stop TB” strategy.
21. Why is diagnosis of TB difficult in HIV positive persons?
22. Mention the new drug for TB? Bedaquiline
23.Stop TB
24. End TB