Sample annotated Clinico-social Case for Community medicine undergraduate training by Dr. Mandar Baviskar, of Dr.BVP RMC, Pravara Institute of Medical Sciences (DU), Loni

1. The Art and Science of
Case Presentation
Dr. Mandar Baviskar M.D.
Associate Professor-Community Medicine,
Dr. BVP RMC, PIMS(DU), Loni
“Life is short, art long, opportunity fleeting,
experience treacherous, judgment difficult.”

2. Why should you learn Case Presentation?
 Disciplines the Mind to note the Facts (Eyes cannot see what the mind does not know)
 The patient feels good (Doctor ne sahi se janch ki)
 You can communicate the findings better to your peers
 Helps in follow up visits (Swelling dimensions have increased/Icterus has reduced)
 Medico-legal purposes
 Meticulous patient records helps with Research
A GOOD DOCTOR KNOWS -WHAT TO DO
A GREAT DOCTOR KNOWS -WHAT NOT TO DO

3. Format (sample case)
A] Socio Demographic Profile of the Patient
 Name: Mr. Kishan D.
 Age: 36 years
 Sex: Male
 Education: 10th pass.
 Occupation: Driver
 Marital Status: Married
 Socio-Economic Status(SES): Lower Middle Class (Modified BG Prasad, 2019)
 Family Type: Three Generation
 Religion/Caste/Category: Hindu/Chambhar/ (SC)
 Residence: Ashwi Kd.
While presenting condense the
information in sentences. Ask
awkward questions like SES at
the end, once the patient is
comfortable, but present in
order.

4. Chief Complaints
In Patients words/Chronological
1. Bodyache since 7days
2. Fever since 6 days
3. Yellow coloured urine since 3 days
4. Yellowish Discolouration of Eyes and Face since 2days

5. History of Presenting Illness
 The patient was apparently alright 7 days ago when he started having
bodyache which was gradual in onset, moderate in intensity, and involved the
whole of the body(diffuse). It was associated with burning of eyes and was
relieved on medication (tab. Diclofenac). The patient attributed it to
prolonged driving and continued with daily routine.
 The fever was mild and continuous, but subsided on medication, there was
associated loss of appetite.
 The patient noted passing dark coloured urine 3 days back which was NOT
associated with frequency, urgency, burning, pain or discomfort.
 Two days back the patient’s wife noted yellowing of eyes and face of the
patient, following which he was brought to medicine OPD and was admitted in
the WARD for further investigation
I add additional info in brackets- To
be told, only if asked

6. What more should be asked?
What all will you rule out?

7. Past History
 The patient has NO history of similar complaints in past
 There is NO history of Diabetes, Hypertension, Tuberculosis, Asthma, Major
Cardiac diseases, Alcoholism, Liver Disease, COVID infection
 There is H/o recent and frequent work related travel in past 6 months

8. Personal History
 The patient has no addiction to Tobacco, Alcohol
 The Sleep is Uneven and often altered due to the profession
 The Appetite is reduced
 Bowel & Bladder habits have not noticeably altered
 Does not report High risk sexual behaviour or contact

9. Family History
The patient belongs to a Three Generation Family. No similar complaints
in the family
Name Age Sex Ed. Occupation Relation to Ptn. Health Complaints
Dadoji 64 years Male - Retired
Factory
worker
Father Hypertension since
4 years. Past H/o
TB. Chr. Bronchitis
Tobacco Addiction
Rukhmabai 60 years Female - Homemaker Mother -
Rekha 30 years Female 5th Homemaker Wife -, Underwent TL 2
years back.
Sanjay 8 years Male 4th School going Son -, Immunized till
date
Swara 6 years Female 2nd School going Daughter -, Immunized till
date
Always ask the examiners if they want a salient features
or should you elaborate on Family history table

10. Dietary History
The patient consumes mixed diet (Non veg at least 1 time/wk.)
Calorie req.: 2300, Consumption: 2000, Deficit: 200
Protein req.: 75 grams, Consumption: 66 grams, Deficit: 9 grams
Time Item Calories Proteins
Breakfast Rice (1 wati)
Dal(1 wati)
Chapati 2
Vegetable (1 wati)
Tea 1 cup
300
300
200
150-400
50
10
16
5
5
-
Lunch Sabzi/ Dal tadka
Roti 2
300
300
10
5
Evening Snacks Tea 1 cup
Biscuits/Chips
50
150
-
Dinner Dal Khichadi (1 plate) 300 15
Total 2100-2450 66
Ask if you should you elaborate on Diet

11. Occupational History
 The patient is driver by occupation and has been driving since age of 20 (16
years)
 Patient currently owns own car Toyota Innova and travels commercially all
over the country.
 The patient has ferried many college students after lock down to various
educational institutes.
 Does not have any major complaints except musculoskeletal fatigue and
occasional eye stain with regards to travel.

12. Environmental History
 The patient lives in Pucca house, with 3 rooms. Electricity with inverter
 There is no overcrowding.
 Patient has piped water supply in house. Filter is used to purify drinking
water. Water stored in metal containers. Dry day not observed. Water
covered.
 Cooking gas is available (Subsidized). Orange Ration Card
 No mosquito breeding sites reported near house
 Garbage Dumped in Common area in the village
 Separate Private Toilet with water facility.
 Owns two cows. Shed is more than 15 feet away from house, wife, father and
mother tend to the cattle.

13. Socio-Economic Status and Spending
 Sole earning member. Driving is primary source of income. Milk from cattle is
secondary source.
 No agricultural land
 Belongs to Lower Middle Class of BG Prasad Scale
 Owns cooking gas, Dish TV
 Major Expenses are Electricity, School Fees and Utilities of Children (ZP
school), Dish TV, Mobile bills, Car maintenance, Groceries and Daily Living
 Goes to private practitioner for minor health problems and comes to Pravara
Hospital for Major health issues. Avg. Out of Pocket Expenditure on Health is
300 rs. Per month
 Has life insurance cover, car insurance, Invests in bank FD and no outstanding
Loan.

14. Health Beliefs and KAP
 Believes Kawil occurs by bad water and NOT due to Divine Intervention
 Trusts doctors to treat
 Did not visit any quacks before coming to hospital.
 Has religious thread on hand for protection against evil eye since childhood,
prescribed by family members.
 Usually carries own water bottle in car but admitted to drinking water at
Dhabas during past months as he was touring
 Knows about boiling water, has a filter at house for drinking water

15. WHAT DO YOU THINK NOW?
 Differential Diagnosis:
1.
2.
3.
4.
 Probable Diagnosis:

16. Clinical Examination
 General Examination: Patient is thin built, well oriented to time place and
person and lying down supine on the bed when examined.
 The BMI was 22.
 Vitals: Pulse:80/min, BP: 110/80 mmHg (Rt. Arm Supine), RR: 16cpm
 Pallor-Absent
 Icterus-PRESENT on Eyes & Skin, Absent on Palms and Sole of foot
 Clubbing- Absent
 Cyanosis-Absent
 Oedema- Absent (Face/Sacrum/Foot)
 Lymphadenopathy- Absent (Neck, Axilla, Groin)
 Head to Toe Examination: ???

17. Systemic Examination
Abdomen RS CVS CNS
Inspection
Palpation
Percussion
Auscultation
Other/Local Examination:

18. Diagnosis
 Mr._______________________________a ____yr______who is
_______________by occupation is likely suffering from
 ____________________
 complicated by____________________ with
 _______________________________________________ risk factors
contributing to the condition.
What investigations and treatment will you advice?
How will you manage the patient?

19. RECOMMENDATIONS
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
To specific
individuals/
index case
To the family on
the whole
To the
community at
large

20. “
”
Nothing will sustain you more potently than the power
to recognize in your humdrum routine, the true poetry
of life—the poetry of the commonplace, of the plain,
the toil-worn, with their loves and their joys,
their sorrows and their grief.
Sir William Osler
Thank you