Case discussion format for UG medical students in Community medicine

1. CLINICO-SOCIAL CASE
FORMAT DISCUSSION
Dr. A. BALAJI MD.,
Professor and Head,
Community medicine,
Tagore Medical College and Hospital.

2. Case list – One Long case
Communicable &
Non- Communicable
Diseases Maternal and Child Health
 Tuberculosis
 Leprosy
 Fever –
Malaria/Dengue/Viral
hepatitis
 PUO – HIV/Typhoid
 Type 2 Diabetes
 CVD/IHD/SHT
 Antenatal
 Post natal
 Adolescent anemia
 Under five case
 Acute respiratory illness
 Acute diarrheal disease
 Malnutrition / Under
nutrition

3. What is the difference between Community
Medicine history taking and Clinical Medicine?
 Assessment of:
 Socio economic status – Occupation,
Education and Income
 Environmental conditions – Environmental
history
 Nutritional status – Complete Dietary history
 Family background – Complete family history
 Socio cultural factors or determinants - Socio
cultural history – Socio cultural factors

4. PURPOSE

5. General Information of the Patient
 Name
 Age
 Gender
 Complete Residential address (door number,
street, locality, area) –
 (To assess on certain epidemiological factors like
epidemic/endemic nature, geographic trends, follow
up)
 Educational status level - Important to assess the score
for SE status
 Occupation (type of job and nature of job) –
(nature of job – sedentary/moderate/heavy)

6. TYPES OF WORKERS
 Sedentary worker
 Mostly resting with little or no planned strenuous activity
 E.g: Bank employees, Software engineers
 Moderate worker
 Mostly standing or walking work environment or daily
planned strenuous activity
 E.g: Teacher, Watchman, factory employees or supervisors
etc
 Heavy worker
 Working environment is strenuous or routine strenuous
activity for several hours
 E.g: Rickshaw pullers, Daily Construction workers

7. TYPES OF WORKERS
 Unskilled
 Jobs which require the experience of little of no
independent judgment or previous experience
 E.g: 1.Peon 2.Packer 3.Watchman 4.Cleaner
5.Sweeper
 Semi-skilled
 A semiskilled worker which is typically more routine
or equipment-driven needs experience where
important decisions made by others.
 E.g: 1. Security guards 2. Waiter 3. Truck or taxi
drivers
 Skilled
 A skilled employee is one who is capable of working
efficiently with independent judgment and of
discharging his duties with responsibility.
 E.g: 1. Electrician 2. Mechanic 3. Tailors 4. Nurses

8. COMPLAINTS OF THE PATIENT
 Chief presenting complaints
 (1 OR 2 complaints that made the patient to
come to the hospital)
 (Present it in chronological order)
 H/O presenting illness
 Elaborate the chief complaints (duration, mode
of onset, severity, aggravating and relieving
factors)
 Associated symptoms (related to the system
involved) – Cardinal symptoms of the particular
system involved

9. CHIEF COMPLAINTS
HISTORY OF PRESENTING
ILLNESS
 Cough with expectoration
for the past 20 days
 Fever for the past 5 days
 The patient was
apparently normal before
20 days
 The cough started 20
days onwards initially it
was dry and then
gradually presented with
expectoration, mild yellow
colored sputum and
occasional foul smelling,
the cough was more
during the night while
lying down relieved in

10. CARDINAL SYMPTOMS OF A SYSTEM
CARDIOVASCULAR
SYSTEM
RESPIRATORY SYSTEM
 Chest pain
 Breathlessness
 Palpitation
 Syncope
 Breathlessness
 Chest pain
 Cough with
expectoration
 Hemoptysis
 Wheeze

11. PAST HISTORY
 H/O Tuberculosis
 Systemic Hypertension
 Diabetes Mellitus
 Chronic Medical Illness
 Previous surgeries
 Associated illness
 Duration, Treatment for the illness
 Complications due to the illness

12. PERSONAL HISTORY
 Smoking
 (duration, age started smoking, type [cigar/beedi/any
other], frequency [number] per day, any withdrawal
symptoms
 Alcoholism
 (duration, age started, type of alcohol, frequency and
quantity per drink, any withdrawal symptoms]
 H/O of any drug abuse:
 (name of the drug, frequency of use, any withdrawal
symptoms)
 Bowel/bladder habits – Altered / Normal
 Sleep-wake cycle

13. FAMILY HISTORY
(Residing in the same house)
S.No Name of the
family member
Relationship
to the Head
of the family
Education Occupation Income H/O Similar
illness in the
family
1. Raja HOF Graduate General
manager
60,000
/month
Has
Recurrent
Respiratory
illness
2. Rani Wife Graduate Home
maker
Nil No
3. Vasu Son 8th STD _ _ H/O similar
illness a
month ago
4. Lakshmi Daughter 3rd STD _ _ H/O Similar
illness 15
days ago
TOTAL
INCOME
60K / Month
Percapita =
60,000/4 =
15,000/Head
Calculate
Per capita
income

14. PEDIGREE CHART
 Pedigree Analysis
 Important tool for studying human inherited diseases
 Used to determine the mode
of inheritance (dominant, recessive, etc.) of genetic
diseases.

15. PEDIGREE CHART
 Family with generations • Easier to visualize relationships
with in families, particularly large
extended families.

16. COMMON QUESTIONS IN FAMILY
HISTORY
 Define family
 Types of family
 Modern family
 Pathological and problem families
 Role of family in health and disease
 Per capita income of the family and its
calculation

17. TYPES OF FAMILY
 FAMILY – A group of biologically related individuals living
together and eating from a common kitchen.

18. TYPES OF FAMILY
 Nuclear family
 Married couple and
their children while
still they are
dependants
 Extended or
Three generation
 Young couples
living with their
parents and have
their own children

19. TYPES OF FAMILY
 Joint family
 Consists of a number of
married couples and their
children living together in
the same household;
 All the men are related by
blood and the women are
their wives, unmarried
girls and widows of the
family kinsmen.

20. PROBLEMS IN THE FAMILY
• Problem family - Poor standard of living, financial
problems, psychological or personality problems in
family members
• Broken family – Single parent

21. SOCIO-ECONOMIC STATUS (SES)
CLASSIFICATIONS
 Modified BG Prasad’s classification
 Used for both urban and rural areas.
 Most commonly used scale to measure the Socio-
economic status of families.
 Devised in 1961 and was later modified by the author
himself in 1968 and 1970
 It is based on per capita monthly income.
 Limitation:
 Only Income is taken into account
 Miss out on the other factors affecting the social status of
the individual.

22. Modified BG Prasad classification - 2019
Social class Revised for 2019 (income Rs / Month)
Class 1 7008 and above
Class II 3504 – 7007
Class III 2102 – 3503
Class IV 1051 – 2101
Class V 1050 and below

23. MODIFIED KUPPUSWAMY SCALE
 Most commonly used scale for determining the SES in
urban and peri urban areas
 Three parameters:-
 Education
 Occupation, and
 Income of the individual
 This scale enables SES assessment of a family rather
than an individual
 The parameters were modified as education and
occupation of the HOF and the pooled income of the
whole family
Head of the family
Pooled family
income

24. MODIFIED KUPPUSWAMY SCALE

25. Other SES Classifications
 Uday Pareekh classification is used for rural areas
 The following characteristics namely:
 Caste
 Occupation of family head
 Education of family head
 Level of social participation of family head
 Landholding, housing, farm power, material possessions
and
 Type of family
 Hollingshead in USA employed three variables
 Education
 Occupation and
 Residential address

26. Socio economic status:
(Using modified kuppuswamy classification/BG Prasad
classification)
 Modified BG prasad
 Total income - 60,000
 Number of family members
– 4
 Percapita income = Total
income / Number of family
members
 Percapita income = Rs.15,000
 This family in this example
Belongs to Class 1
 Modified kuppuswamy
classification
 Education of the head of the
family - Graduate - 6
 Occupation of the HOF
 General manager – 6
(Semiprofession)
 Family– 12 income- Rs.
60,000
 6+6+12 =24 =Upper Middle

27. DIETARY HISTORY
 Use 24 hours recall method
 Ask the patient regarding his diet consumed
the day before
 It should be converted into calories and
proteins approximately
 Compare it with the reference standard.
 RDA – for that particular age group, using the
Indian reference men / women criteria
 Comment on the calories (excess/deficit)

28. Common Questions related to
Dietary history
 What are the methods of assessment of nutritional
assessment?
 What is one dietary cycle?
 What are the methods of assessment of dietary
intake?
 Recommended daily allowances for Calories,
proteins and vitamins for different ages – especially
under five years and antenatal mothers
 Criteria for Indian reference Man and Woman

29. Discussion

30. Discussion

31. ENVIRONMENTAL HISTORY
 Type of house (Pucca/Semi-pucca/Kutcha)
 Situation/location
 Set back (present / absent)
 Floor, roof, walls, windows, number of rooms
 Ventilation: adequate/inadequate
 Lighting: adequate/inadequate
 Separate kitchen: yes/no (method of storage of food
materials). Fuel used, exhaust+/-
 Garbage disposal
 Separate store room: Storage of raw materials
 Separate toilet
 Habit of Open air defecation

32. Environmental history
 Overcrowding: (define according to number rooms
per person, space availability/sex separation)
 Solid waste: storage, transport, disposal (frequency
of disposal from the house)
 Water: Source, storage, palatability, color, odor,
whether the water is disinfected or not. water used
for cooking purpose
 Peri-domestic sanitation: Fly breeding and mosquito
breeding source
 H/O pet animals: If yes detailed history of the
premises of the animals reared. Immunization history
of the animals, cleaning of the animals, animal
excreta disposal
 Pest/rodent menace +/-

33. Questions asked in Environmental
history
 Housing standards
 Solid waste disposal methods adopted by this
family (read all the methods of solid waste
disposal methods)
 Define sewage, Sewage disposal methods
 Sanitation barrier?
 Public health importance of proper disposal of
sewage and solid waste
 Definition of overcrowding

34. Discussion
 Types of houses – Kutcha (thatched roof with mud
walls), Semi Pucca (Tiled roof) and Pucca
(Cemented roof)
 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 living room should be
provided with at least two windows and one of them
should open directly to an open space.
 Cross ventilation: Doors and windows should be
placed opposite to each other. i.e. air should pass
through one end and come out at the other.

35. Discussion
 Overcrowding
 Persons per room – overcrowding exists if it exceeds the
following criteria
 1 room – 2 persons
 2 rooms – 3 persons
 3 rooms – 5 persons
 4 rooms – 7 persons
 Floor area - overcrowding exists if it exceeds the following
criteria
 110 sq ft – 2 persons
 90 – 110 sq ft – 1½ persons
 70 – 90 sq ft – 1 person
 50 – 70 sq ft – ½ person
 Sex separation – Overcrowding is considered to exist if 2
persons over 9 years of age of opposite sex, not husband and
wife, are obliged to sleep in the same room

36. Socio cultural history (Pertaining to the
case)
 Knowledge about the disease
 Attitude towards the disease (Approach
towards the disease)
 Practice
 System of medicine (Allopathy
/AYUSH/Indigenous or Native medicines -Local
cultural habits/beliefs/customs
 Useful in making the community diagnosis

37. OTHER IMPORTANT HISTORIES
(CASE SPECIFIC)
 Immunization History & Developmental history
 Under-five case/Severe Malnutrition etc
 Drug history/Treatment history
 Drug intake, duration, frequency per day, dose if the patient
knows etc
 Menstrual History
 Antenatal /PNC /Adolescent girl with Anemia
 Marital history: Antenatal /PNC
 Dietary history for infant case
 When breast feeding was started after delivery, pre lacteal
feeds, colostrum, exclusive BF, weaning

38. General Examination and
Systemic examination

39. DIAGNOSIS
 PROVISIONAL DIAGNOSIS
 INDIVIDUAL-– ABOUT THE DISEASE IN THE
INDIVIDUAL Age, gender, diagnosis with/without
complications
 COMMUNITY DIAGNOSIS
 INCLUDE THE FACTORS LIKE (SOCIAL, CULTURAL,
FAMILIAL, ECONOMIC, ENVIRONMENTAL FACTORS)

40. Example of provisional and community
diagnosis
 Provisional diagnosis
 55 year old male
 chronic non healing wound on the
right foot is diagnosed to have
 Type 2 Diabetes Mellitus
 With complications (Peripheral
Neuropathy)

41. Community diagnosis
 55 year old male with
 chronic non healing wound on the right foot,
 with history of other symptoms of diabetes,
 coming from an urban slum
 working as an auto driver with SES class IV
 and overcrowding at the house
 with high BMI
 consuming normal calories for his age and gender
and
 a chronic alcoholic with poor knowledge on diabetes
treatment
 underwent an indigenous treatment for the
management of wound.

42. MANAGEMENT
 WHICH LEVEL OF PREVENTION IS
FAILED?
 MANAGEMENT
 INVESTIGATIONS
 TREATMENT
 HEALTH EDUCATION
 INDIVIDUAL AND FAMILY

43. Exam tips
 Recall (few minutes) all the history and subheadings to
be asked to the patients – Do not rush in asking the
questions while history taking
 Let it be like a conversation (Not like interview or
question and answer session)
 Start with some general conversations like wish the
patient, introduce yourself
 Develop a rapport
 Be polite towards the patients
 Write legibly (Case sheet) – readable by the presenter
and the listener (examiner)
 Do not start with diagnosis when you start presenting the
case to the examiner