Clinico-social case format for diarrhoea, demographic details, chief complaint, history of presenting illness, treatment history, past history, brief antenatal history, birth historym postnatal history, developmental history, nutrition history, immunisation history, personal history, family history, socio-economic / psycho-social history, environmental history, KAP about the disease, general examination, systemic examination, local examiantion, investigations, summary and case management.

1. Clinico Social Case – Under 5
Child: Briefing
Dr. Jayaramachandran S
Associate Professor
Department of Community Medicine
10.09.2020

2. Global response: SDG 3
• The SDG Goal 3 is to end preventable deaths of newborns and under-
5 children by 2030.
There are two targets:
• Reduce newborn mortality to at least as low as 12 per 1,000 live
births in every country (SDG 3.2)
• Reduce under-five mortality to at least as low as 25 per 1,000 live
births in every country (SDG 3.2)

3. Key facts
• In 2018 : 6.2 million children and adolescents <15 years died –
preventable causes.
• Of these deaths, 5.3 million < 5 years, with 50% in neonates
• Leading causes of death in children under-5 years are preterm birth
complications, pneumonia, birth asphyxia, congenital anomalies,
diarrhoea and malaria.
• Nearly half of these deaths are in newborns.

4. Self and patient Introduction
• Smile and welcome the mother and child
• Introduce yourself and verify the identification details of the patient
• Informant: Mother Reliability: Good
• What is the problem with your child/ grandchild?
• Opening statement: The child is lethargic and not active
• Reassure the child’s informant and calm down the mother

5. Socio-demographic profile

6. Socio-demographic profile
• What is the name and age of the baby?
• What is your (of the mother) name and age?
• What is your husband’s name and age?
• What is your educational qualification? and your husband’s
qualification?
• Are you working?
• What is the occupation of your husband?

7. Socio-demographic profile
• What is the total income of the family?
• Where are you currently residing?
• Which is the nearest government and private hospital / clinic and how
far it is from your house?
• To which hospital / clinic do you take your child in case of minor and
major illness?

8. Chief complaints

9. Chief complaint
• What is the problem that made you bring your child to the hospital?
• How long?

10. History of presenting complaints

11. History of presenting complaints:
• LQ: Then did she have any diarrhoea or vomiting?
• When did she start having diarrhoea?
• How often she had diarrhoea?
• How was the onset? How did it start?
• Consistency of the stool? LQ: was the stool watery or semi-solid?
• Frequency of stool? How often did she pass stool in day?

12. History of presenting complaints:
• Each episode of diarrhoea lased for how many days?
• Did the stool smell foul?
• Was it mixed with blood?
• What is the volume of stool passed?
• Aggravating and relieving factors?
• Then what happened?

13. History of presenting complaints:
• Did the child have h/o any abdominal pain, nausea, vomiting?
• Did the child pass worms in stools?
• Did the child have any h/o constipation?
• Does the child pass urine?
• Does the child drink fluid? How much?

14. History of presenting complaints:
• Did the child had any h/o difficulty in breathing or dysponea on
excretion or hurried breathing?
• Did the child had any h/o palpitations or chest pain or squatting
episodes?
• Did the child had any h/o weakness of upper / lower limbs, seizure,
unconsciousness, etc.
• Any other symptoms

15. Treatment History

16. Treatment History
• What treatment was given for recurrent respiratory tract infection?
• What treatment was given for diarrhoea?
• Has the child been dewormed?
• Any other treatment?
• Is the child allergic to any drugs?

17. Past history

18. Past history
• Past medical history: LQ: had the child been given treatment for any
minor problem or had been hospitalized for any major problem
before 6 months?
• Past surgical history: LQ: has the child undergone any operation?

19. Antenatal history of the mother

20. Antenatal history of the mother
• What is the age of the mother at marriage and pregnancy?
• What is the weight of the mother at pregnancy?
• Is the mother immunized for her age?
• Did you get registered in the PHC during pregnancy?
• If Yes, Where? And why?

21. Antenatal history of the mother
• Did you take any tablets during your pregnancy?
• What tablets did you take and for how many days in which trimester?
• Was anomaly scan done? If so, which month of pregnancy?
• Was any vaccine given during your pregnancy? If so, which vaccine?
When and where was it given?

22. Antenatal history of the mother
• Do you have any h/o exposure to radiation during pregnancy? LQ: did
you take any x-ray during pregnancy?
• How many times did you go for check up and where?
• How much weight did you gain during your pregnancy?
• Any h/o previous pregnancy?
• Any h/o of contraceptive usage?

23. Child’s birth history

24. Child’s birth history
• Where, when and how was the child born?
• Did the child cry immediately after birth?
• After how much time from child birth did you 1st breast feed the
child?
• Was the child given anything else apart from breast feeding?
• What is weight of the child at birth?
• Are you told that the child is having any congenital defects?

25. Post-natal history

26. Post-natal history
• Was the mother and child healthy during the post natal period
• Was there any illness due to which the mother and child was
separated?
• How many times did you go for follow up during your postnatal
period?

27. Developmental history

28. Developmental history
• There are five areas of development according to the functional skills.
• Gross motor
• Fine motor
• Speech and language
• Social development, adaptive skills, and general understanding
• Hearing and vision

29. Developmental history
1. When did the child attain the following gross motor milestones
Head control 4
Sitting with support 6
Sitting without support 9
Standing with support 7
Standing without support 11
Walking with support 11
Walking without support 13

30. Developmental history
2. Fine motor skills includes advanced hand skills, hand eye co-
ordination, hand mouth co-ordination, etc. These can be tested by
the use if cubes, writing, feeding, dressing, etc
When did the child attain the following fine motor milestones
Reaches for an object with both hands 4
Drinks from cup when help to lips 4 – 5
Reaches for an object with one hand 6
Can hold a bottle and drink 6 – 7
Tries to reach for toys which is out of reach 8
Releases object on command 12

31. Developmental history
Can drink a cup of milk 15
Can feed without help 15
Can feed self with spoon with spilling 15
Can imitate scribble 15
Can build tower of 2 cubes 15
Can hold 2 cubes in one hand 15
Can feed self without help 15

32. Developmental history
3. Various factors play a role in the development of speech. When
did the child attain the following Speech and language milestones
Smiles and vocalizes 2
Laughs aloud 4
Mono syllable (Ma) 6
Combines syllable (mama) / imitates sound 8
Speaks 1 word with meaning (no) 10
Speaks 2 words with meaning 12
Can name a familiar object 14
Can name pictures 16

33. Developmental history
4. When did the child attain the following Social development,
adaptive skills, and general understanding milestones
Smiles and vocalizes when spoken to 2
Can turn his head when called 4
Will stretch arm when mother tries to lift 6
Responds to own name 8
Deliberate dropping of things 10
Comes when called 12
Feeds –self – no help needed 15
Bladder control (in months) 15 – 18

34. Developmental history
5. When did the child attain the following Hearing and vision
milestones
Hearing (To test hearing of the baby, make a sound at about 18
inches from the ear)
Turns the head to the side of the source of sound 3 – 4
Turns to one side and looks down if the source of
sound is below the level of ear
5 – 6
Can imitate sounds 7 – 8
Turns the head diagonally towards the source of sound 8 – 10
Localizes the sound source like adults 12

35. Developmental history
Vision (vision is tested after 3 years using snellen’s chart) – ability
of the child to name, copy or match letters or numbers.
Infant eys’s follows the object 2
Hand regard 3 – 5
Binocular vision 4
True co-ordination of the eyes and hands 6

36. Nutritional (Diet) history
• Diet history of the child is recorded using 24 hours recall method.
• Please tell me the details of type of food given to the child between yesterday 6
am to today 6 am along with the time during which it was given and its quantity.

37. Nutritional (Diet) history
Time Item Quantity
Caloric
value
(Kcal)
Protein
content
Fat
content
Morning
6 – 8 am
Milk (Cow’s) 100 ml 90
-- -- -- -- --
-- -- -- -- --
8 – 10 am
Idly 2 75
Sambar ½ cup 55
-- -- -- -- --
10 am – 12 noon
Milk 100 ml 90
-- -- -- -- --
-- -- -- -- --

38. Nutritional (Diet) history
Time Item Quantity
Caloric
value
(Kcal)
Protein
content
Fat
content
Afternoon
12 noon – 2 pm
Rice ½ cup 85
Curd ½ cup 70
Papad 1 30
2 – 4 pm
-- -- -- -- --
-- -- -- -- --
-- -- -- -- --
Evening
4 – 6 pm Biscuit 2 50

39. Nutritional (Diet) history
Time Item Quantity
Caloric
value
(Kcal)
Protein
content
Fat
content
Night
6 – 8 pm
Rice ½ cup 85
Sambar ½ cup 55
Milk (Cow’s) 100ml 90
-- -- -- -- --
8 pm – 6 am
-- -- -- -- --
-- -- -- -- --
-- -- -- -- --
Total 775

40. Nutritional (Diet) history
Expected calorie intake: Calorie and protein requirements
Weight of
the child
(kg)
Daily requirement
of calorie (kcal /
kg)
Age
(months
)
Calorie
(kcal/kg/d
)
Protein
(g/kg/day
)
Frequency of
feed
< 10 100 0 – 3 120 2.2 • Initially: every
4 hrs as per
demand
• 6 – 9 feeds by
1st week of life
• 3 – 5 meals by
9 – 12 months
10 – 20 1000 + 50 4 – 6 115 1.8
> 20 1500 + 20 6 – 9 110 1.8
1000 Kcal for 1 year and
add 100 kcal/ year up to
12 years
9 – 12 105 1.5

41. Nutritional (Diet) history
Expected Intake
Deficient /
excess
Remarks
Calorie intake 1050 775 - 375
Protein intake
Fat intake

42. Immunization history
• Do you have the child and the mother card? Immunization card?
• If Yes, can you please show me?

43. Immunization history
• Was the child given any vaccine at birth?
• If so, how many? And when
• So when did the child had the first vaccine
• Then when was the next vaccine given?
• Then at 9 month vaccine along with vitamin A
• Any other vaccines given?

44. Personal history

45. Personal history
• Does the child take non-vegetarian diet
• For how much hours the child sleeps
• How many times does the child pass urine in a day
• How many times does the child pass urine in a day
• Does the child prefer any particular food? If yes, which item?
• Does the child avoid any particular food? If yes, which item?

46. Family history

47. Family history
• Types of family
• Vulnerable group
• Composition
• Social issues: unemployment / school dropout / illiteracy
• Vital even: birth/ death/ marriage last year
• Consanguinity
• Inference
Name Relation to
head
Age/ sex Education Occupation Marital
status
Remarks

48. Socio Economic / Psychosocial
History

49. Socio Economic History
• Total income of family - direct / indirect / govt. source
• Per capita income of family - SES: Modified Updated BG prasad score
• Do they belong to BPL?
• Expenditure pattern [ food, house rent, house utilities, health, saving,
debts, recreation, others]
• Inference

50. Psychosocial history
• Effect of disease on the family
• Patient relationship with family member
• Patient relationship with community
• Co-operation of family with patient
• Social issues – depts/ rivalries/ family issue
• Family relationship with community

51. Environmental History

52. Environmental History: External
• Area map: with important places
• Open field defecation in
community
• Road side drainage –
Open/closed
• Stray dogs – Yes/No
• Vector reading sites in
community
• Lightning on road –
adequate/inadequate
• Hazards in community – For
accidents, for environment
• Noise pollution

53. Environmental History: Internal
• Housing plain and house
• Kitchen
• Water supply
• Latrine
• Water management

54. Environmental History: Internal – Housing
• House plan diagram with
measurement (rough)
1. Ownership
2. attached/independent
3. Setback
4. Type of house
5. Floor-even/uneven
6. Roof-thatched, asbestos and
others
7. Leakage
8. Crack
9. Dampness
10. Number of living room
11. Overcrowding
12. Ventilation/lightning
13. Area prone to
injuries/accidents

55. Environmental History: Internal – Kitchen
• Separate
• Fuel used
• Smoke outlet
• Platform
• Kitchen garden
• Sewage disposal
• Soot particles
• Storage of -(Raw food,
Vegetables, Cooked
food/Leftover food)

56. Environmental History: Internal – Water supply
Drinking Purpose
• Source of water supply
• Quality of water
• Distance
• Regularity
• Sufficient
• Storage
• Method of purification / drawing
Other purpose
• Same + observe for physical
qualities – turbidity
• [bore/motor-usage/how many
houses]
• [overhead tank / sump]

57. Environmental History: Internal – Bathing
• Bathroom – Present/absent
• Privacy – Yes/no
• Lightning –
adequate/inadequate
• Maintenance – Good/poor
• Accident prone areas
• Drainage for bathroom
• Latrine– present/absent
• Latrine Used / Shared
• Type: water seal/no water seal
• Open field defecation
• Lightning/maintenance/adequat
e place
• Septic tank/other drainage

58. Environmental History: Internal – Waste management
• Separate dust bin
• Waste segregation
• Frequency of disposal
• Methods? Where
• Specifics waste? (sputum)

59. Environmental History: Vector and animals
• Presence of vector
• Control measure
• Rodents
• Pet animals
• Cattle shed

60. KAP about disease

61. KAP about disease
• Knowledge (about disease/issue)
• Attitude (willingness towards system)
• Practice (doing?)
• KAP about existing problems/other family members/vulnerable

62. General Examination

63. General Examination
• Built and nourishment
• Pallor
• Icterus
• Cyanosis
• Clubbing
• Pedal oedema
• Generalised lymphadenopathy
• Vital signs
−Pulse rate
−Respiratory rate
−Blood Pressure
−Temperature
• Anthropometric measurements

64. Head to Toe examination

65. Systemic Examination

66. R. Systemic Examination
• Cardiovascular System Examination
• Respiratory System Examination - ARI
• Gastrointestinal system Examination - ADD
• Neurological System Examination

67. Local Examination

68. Local Examination
• Skin examination – external markers
• Injury or Ulcer in lower extremities
• Oral cavity examination
• Throat examination
• Nasal cavity examination
• Ear examination

69. Summary

70. Summary
• Family of Mr. X residing in __________ belong to ______SES.
• Positive facts and problems in the individual
• Health demands and Health needs of the individual
• Vulnerable individuals in the family
Positive Negative
Medical
Social
Environment
Nutrition

71. Investigation required

72. Investigation required
• Complete Haemogram – Haematological Disorders
• ARI –TC, DC, ESR, chest x-ray (if required for diagnosis)
• Diarrhoea – stool culture & sensitivity, Stool for ova/cyst
• Recurrent resp. tract infection: ECHO, ECG
• LFT – Liver Disorders
• RFT – Kidney Disorders

73. Plan of management

74. Plan of management
Relevant National Health Programs
−To the case – disease + other associations
−To the family
−To the community
Individual Level Family Level Community Level

75. Case scenario:
• Name: Ramya
• Age: 4 years from Villianur
• Father: 30 yrs Daily Wager / Rs. 5000 per month / 10th Std
• Mother: 22 yrs / Going for 100 days job / Graduate
• Chief complaint: Diarrhoea – for 3 days
• Treatment history: Saw treatment in near by PHC and referred
• Past history: recurrent infections – ARI / diarrhoea, nil surgical

76. Case scenario:
• Antenatal and child birth history: Normal
• Postnatal history: Normal
• Developmental: Normal milestones
• Nutritional history: Deficient intake by 500 Kcal
• Immunisation: Immunized for age
• Family members: 5 yr female / last immunisation not taken / 16 kg

77. Case scenario:
• Personal history: Pica+/ reduced micturition/ increased bowel
movement
• Environmental history: Kutcha house, waste disposal (solid and liquid)
poor, housing: overcrowding +, indoor air population +, can water for
drinking, kitchen – not hygienic, toilet – hand washing+, vectors +,
otherwise normal.
• SES: ? / Psychosocial history – good support from neighbor & family
• KAP: Poor about diarrhoea management

78. Case scenario:
• General examination: the child is lethargic and dull with sunken eyes,
otherwise normal
• Vitals: Pulse: 100/min, RR- 16/min, BP- 90/60, Temp- 40℃
• Anthropometry : Ht – 100cm , wt – 15 kg, MAC- 13cm – plot in
growth chart and check for malnutrition
• Local examination: Skin pinch goes back very slowly, otherwise
Normal

79. Case scenario:
• Systemic examination: normal on inspection, palpation, percussion
and auscultation. Other systems: normal
• Summary:
• Investigations required:
• Management: Individual / family / community level
• Link to national health programs

80. Thank you…