This document provides a template for conducting a socio-demographic and clinical assessment of a patient with diabetes. It includes sections for collecting information on the patient's identity, family, education, occupation, income, housing, treatment history, diet, personal habits, and more. A physical examination template is also provided to systematically examine all body systems. The assessment aims to understand the patient's health needs, social determinants of health, and develop an appropriate management plan taking into account any relevant national health programs.

1. Clinico Social Case –
Diabetes Mellitus : Briefing
Dr. Jayaramachandran S
Associate Professor
Department of Community Medicine
12.10.2020

2. Socio-demographic profile

3. Socio-demographic profile
• What is your name?
• What is age or DOB?
• What is your highest educational qualification?
• Where are you working? How long? Nature of work?
• What was your previous occupation?
• How many family members?

4. 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 treatment for minor and major
illness?

5. Modified updated Kuppuswamy’s SES scale – Aug 2020

6. Modified updated Kuppuswamy’s SES scale – Aug 2020

7. Modified updated Kuppuswamy’s SES scale – Aug 2020

8. Modified updated Kuppuswamy’s SES scale – Aug 2020

9. Chief complaints

10. Chief complaint
• What is the problem that made you come to the hospital?
• How long?

11. History of presenting complaints

12. History of presenting complaints:
• When were you apparently normal?
• LQ: when did it start?
• How often?
• How was the onset?
• Progression of the symptom?
• Aggravating and relieving factors?

13. History of presenting complaints:
• Associated symptoms:
• Same elaboration as presenting complaint and other symptoms of the
system involved
• Negative history:
• For other system involvement – cardinal symptoms
• For complications of the probable disease under investigation?

14. History of presenting complaints:
• Did you ever had any h/o palpitations or chest pain episodes?
• Did you ever had any h/o difficulty in breathing or dysponea on
excretion, hurried breathing, etc
• Did you ever had any h/o weakness of upper / lower limbs, seizure,
unconsciousness, etc.
• Did you ever had any h/o abdominal pain, diarrhoea, nausea,
vomiting, etc.

15. History of presenting complaints:
• h/o chest pain / breathlessness
• h/o decrease in urinary output, puffiness of face, etc.
• h/o visual disturbances
• h/o headache / period of unconsciousness with or without weakness
• h/o numbness and burning sensation in the feet

16. Treatment History

17. Treatment History
• Where did you take treatment for your problem?
• What treatment was given?
• What was the compliance to treatment?
• Response to treatment?
• Any allergic history to any drugs?

18. Treatment History
• Are you taking treatment for any other medical condition for longer
duration?
• Have you ever been admitted for any medical or surgical condition in
the recent past? If so, details

19. Past history

20. Past history
• Past medical history: Diabetes / Hypertension / CAD / Pul. TB / Stroke
/ bronchial asthma /
• Past surgical history: LQ: have you undergone any operation?

21. Personal history

22. Personal history
• Married since?
• Predominant Vegetarian / non-vegetarian diet
• How much hours sleep?
• How many times do you pass urine in a day?
• How many times do you defecate in a day?
• Do you exercise? Addictions?

23. Menstrual history for female
patients

24. Menstrual history
• LMP ?
• Cycle ?
• Regular ?
• Flow ?
• Pain ?

25. Nutritional (Diet) history
• Diet history of the patient 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.

26. Nutritional (Diet) history
Time Item Quantity
Caloric
value
(Kcal)
Protein
content
Fat
content
Morning
6 – 8 am
8 – 10 am
10 am – 12 noon

27. Nutritional (Diet) history
Time Item Quantity
Caloric
value
(Kcal)
Protein
content
Fat
content
Afternoon
12 noon – 2 pm
2 – 4 pm
Evening
4 – 6 pm

28. Nutritional (Diet) history
Time Item Quantity
Caloric
value
(Kcal)
Protein
content
Fat
content
Night
6 – 8 pm
8 pm – 6 am
Total

29. Nutritional (Diet) history
Expected Intake
Deficient /
excess
Remarks
Calorie intake
Protein intake
Fat intake

30. Nutritional (Diet) history
• Fruits / vegetable intake
• Junk foods intake
• Percapita Salt intake
• Percapita Oil intake
• Consider food plate concept

33. Family history

34. 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

35. Socio Economic / Psychosocial
History

36. 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

37. 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

38. Environmental History

39. 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

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

41. 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

42. 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)

43. 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]

44. 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

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

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

47. KAP about disease

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

49. General Examination

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

51. Head to Toe examination
• For any external markers of the disease
• Complication of the disease

52. Systemic Examination

53. R. Systemic Examination
• Cardiovascular System Examination
• Respiratory System Examination
• Gastrointestinal system Examination
• Neurological System Examination

54. Local Examination

55. Local Examination
• Injury or Ulcer in lower extremities
• Ophthalmic examination – Fundus
• Oral cavity examination – dental carries / infection
• Skin examination – external markers

56. Summary

57. 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

58. Investigation required

59. Investigation required
• Fasting and Post-prandial blood sugar
• Fasting lipid profile – for cholesterol levels
• Sr. urea / creatinine for renal function
• Urine for microalbuminuria
• ECG / Echo – for cardia status

60. Plan of management

61. 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

62. Case scenario
• A 43 years old male residing at Villianur, Puducherry from an came
with the c/o ulcer Lt foot for the past 1 months and fever for 10 days.
He has visited govt. PHC for treatment and his symptoms persisted.
He is an alcoholic and a smoker for past 15 years. He is a vegetable
vender and has his own shop. He is morbidly obese and no physical
activity. His diet is high fatty and high carbohydrate rich diet. Excess
intake of 700 Kcal. Past history: Known case of diabetes and
hypertension for past 5 years on irregular medication from Govt. PHC.
No other co-morbidities. Environmental factors & other – normal.

63. Thank you…
• Any questions?
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