Old Foodschemes

Welfare Family
/Puech/Semi-pucca
(Sq. Kutcha
Type:
Housing
Aadhaar
card:Ration
s Expenditureincome:
card:
Savings/Debts: conditions
Economic
Animals/Pets:NoHandExcreta RefuseUtensils:
family
Total Kitchen: NoRoofing:
Purification: NatureSource Ventilation: Flooring: Area:
feet) ENVIRONMENTAttitude
age of
through persons
pension: strain washing: of of
disposal:
disposal:Sepafate/Living towards
Ctean/Food
That supply:water:Tiled/Certénted/Mud
PDS: Color/Services:
due on on:
Boilíngched/Tiled/RCC/ per Asbestos
Ade#uate
NO With'soap/Without Covered job:
- to o Diet Householdtatrine GxOLrmw rooms:
Contirdous/Intermittent
economic /Medical items Straining/
/ Gad
860 bins/Open 1
Inadequate
room/Outdoor
cOvered.
care/Recreations/Education:YeS
conditions:
Filter/Purifier and
soap/Before/Public
dumping/House cow
108
der/Stove/Kerosene:
Other NO Adequate/Inadequate
Ventilation:
Fuel: Present/Absent Cross sheets dung
Drains/Septic
tank:hus
latrine Overcrowding:
Storage
eating/After
benefits
Biogas/LPG/Kerosene/Others
Rats/Others:r
Mosquito/ /Open of Lighting: Walls:Number
cottection/Others water: Rented/Own
from
Tank
Brick/Mud/Thatti
ablution
social Adequate/Inadequate of

security: rooms: 6

Porsh

Total typical
In In aFruits Protein
intake Calorie
intake Others Dinner Evening Lunch Brunch midnight.
Record DIETARY
Type
Breakfast
Timings
a
typical
and of
all diet-
vegetable
week, week, foodHISTORY:
Taigan Veg/Mixed:
and
on on
howconsumption drink (24
how
Recommended Food hour
many many Miocsa
eaten
items dietary
days days on
with the recall
do do
you you previous
dietia
Staple
109 quantity
method)
eat eat Actual
intake
vegetables fruit? 524 day
between

midnight
556 295Ya Calorie
Days Deficit/Excess

and
Serving
Amount
Protein
 LOCALAnthropometry
circumference:
Waist
Height:Tongue/Oral
cmbrrro
hygiene: Blood EXAMINATION
15 No Calm, Patient'
Pulse Skin Orientation generalGENERAL
condition
s Customs NFood Habit
(fasting?): Fried Most
radial/femoral/popliteal/dorsalispedis/posteriortibial)
(carotid/brachial/lor/icterus/Cyanosis/Clubbing/BuiPedal
PalPressure:
Radio-femoral
Temperature:
Felt delayVesselNexamination:
ool
lt/Nourishment:
JVP:on
beliefs/Food commonly
of foods
Salt/Pickies
EXAMINATION:
equally rate, -
wall
conscious eating
intake:
^b
rhythm,
in thickARObrle time,
to
outside:
/Papad/usedChutney
al and taboos:) No
\5b(atherosclerosis) placeive:
(If
rnta
peripheral volume cooperat yS
oil:
relevant) and
&touishoo
bt o
Vegetable /Salty
person:
Weight:
Hip kg 6 pulse 8h|in processed
circumference: - Norro Oneciou oil/Butter
110 Respiratoryormal palpation:
\orra
Thyroid tS
edema/Lymphadenopathy/ Frequency foods:
Rsquda netnd or
gheeChura
rate/type:
20min &a ORrR per
/Margarine
week:
Abdomirorotocie rorral
(Notma)
WHR:Vql
0-2808
8 mBMI: lhoi
/Other:
Koilonychia:

No

PROVISIONAL
DIAGNOSIS: examination:
system
Other examination:
Breast Examination
Abdomen: of Central
Auscultation:
Percussion: Auscultation:
Cardiovascular
examination
Palpation: system
Inspection: Percussion:
Respiratory
Palpation:
Inspection:\oco. System
SYSTEMIC

Nervous
EXAMINATION
abrorralitby
dstoed.No System

examination: (relevant

system
111
first)
 Advice examination:
Followup Treatment:
COMPREHENSIVE
MANAGEMENT
PLAN CLINICO-SOCIAL
DIAGNOSIS
FINALINVESTIGATIONS
Advised: LAB
Already
done:EG
on
self
care (ororcoug
CAD,
Gdrogils
practices:

Tie
Arajog
ram vesso\
112

(CAG disane

presenting
illness:H/o CHIEF
COMPLAINTS
Pedigree Type FAMILY
SN Address:
Nearest
facility:
health Religion:
Occupation:Gender:Name:
of Name
the
chart DETAILS
family:
Age/sex
of
family:
Nuclear/Three (Expand
status
HOF to INTEGRATED
Relation
NON-COMMUNICABLE
DISEASE
CASE
if
more
Maritalfamily
generation/ CLINICO-SOCIAL
113
members)
Education
Joint Distance
km: in Caste:
number:
Contact Income:
Education Age:
CASE
Occupation
STUDY

Income

status
Health
 DescibeWhen, ifHave H/o COMPLAINTS
CHIEF Pedigree Type DETALSEpne
FANLY
Atesss
yes,
presenting
acitgna
eaeshes Gendes

where,specify you of
onset ever chart the
and how type: been
famy:
illness: af
it
progression diagnosed family.Nudear
was
diagnosed,
(Pertaining NTEGRATEDANCOSOOALSTUOYCASE
/threegeneration/
Joint
in as ata famlyore TURERCULOSS
CASE
detail. a
case to
which T8)
122 of ebers)
Ecaton lm
tuberculosis?
symptom
Distance
number:
Contact
inone000
made Ocpation Ecatonth
Caste
N n
him km5
seek
income
Km
consultation?
Health
status

HISTORY
PAST
Satisfaction Loss Extra
care:
LossInvestigation:hest DISEASE
IMPACT
For OF
each
visit Nature?
status:yaiodd
complications
History Health BCGScreening
of H/oVaccination ChildName/Dosage/Frequency/Duration:
Home
Details
consultations:
Number ofAtiictis
Nutrition:
Treatment:
Travel: Consultation Vdama Frequency
osital
Referral: Side Places
TREATMENT
of of use effects
QOL/Stress/Tension/ chemoprophylaxis: visit of
wage/work: Who education-
of of
Nom other of byDOT of treatment/Type
with Thoread Firt fee: noticed? familyhealth follow-up/ of HISTORY
Provider: drugs:
services: emi Fe systems
yes Drug member:worker
hne How No
X-ag consumption/
of investigations:
YeS
Pain/Guilt: htan At-to
did of
os medicine
it NOor treatment
manifest?
supervisor:
haoi BldT
a or
Adverse No
123
dëng3 non recetved/
What NO
prescnibed
effect/Diet/Follow-up
its urt was
, advised?
Treatment
Ya putm drugs:Yaraclmol
drugs
details
Mmhho visits:
Vinyn
Tentn
(bE
mg) hoita
 Status/Duration:
Moriedl20Postmenopausal
MARITAL
HISTORY
bleeding:Regular
MENSTRUAL
HISTORY
Age at
typical on
a continuously
spend
Time
days/weekNumber of activities any PHYSICAL
at finvolves
or ACTIVITY eeso
Stress:No
Personality
Type:
History Bowel
menarche:
Total day
least10
min
Does
your
theseof
work
Sleep/appetite:
Hygiene:tnaSaepConsuming
yes, Yes/No,
If Currently Currently
ifHISTORY
yes,PERSONAL
or
of and average
irregular
drug Ifmention
Folonsbladder anyes, using smoking
Construction allergy/
intensity alcoholicmentionduration:
amount any
cycles: work]digging,loads,
[heavyVigorous habits: any
smokeless
related
Work reaction:o ho duration: tobacco
per drink,
NoYna 10
drink:
walking,
light[brisk
carrying beer, tobacco products,
days 6 loads] intensity
Moderate huygjiane 250 s
124 activity wine,
, products
mlfrequency:
orfrequency: such
Contraception:
Child Duration
Age
intensity
Tlac duration:spirits?
as
of Mild [snuff,cigarettes,
attainment
of Yes/No
o 2packab
each chewing
cyclingor
[walking Travel to
&Travel
cycle: places bidl?
of from
menopause: frequency:"Dmy tobacco, Yes/No
per
Recreational
activities
[walking,
cycling] fitness
Sports, betel]: oy

Unemployment,
previous:
Current
and
0CCUPATIONAL
HISTORY Stigma:
Attitude
ATTITUDE
TOWARDS
DISEASE Involvement
Impact
Participation
Societal/Neighborhood
Response GodHISTORY
relations:
Interaction SOCIAL relationships
FamilyFamily LisFamily
tof History
HISTORY
FAMILY OBSTETRICS
G/P/A:
infertility:
History HISTORY
of
who
ImpactResponse
Emotional
support:
Gocd Stress
toward of morbidities/complications
accompanies members H/o of
disease of on
in society with of
TB/DM/HTN/CHD/CVE/Kidney consanguinity:
reason social
festivals/marriages/social
in disease familyoffamily:
present society: screened
on
Inter-familialgroups: towards on to es
and
illness: towards
Go lntra-familial
hospital/getting o-
duration: for
person:Positive
yos
He illness: TB
relationship: coneanqoirogin
i NO
family:
125 relationship:
Sugpotive
drugs:
conidont activities:Possr diseases
yes
H/o of is
exposure sons fhs
ONSd qoirg to
to
patte
to
hazards: ad
he basoQ &tirg
i Hlo
No
Amots) TB
Cois
 Old Food
schemes
Welfare Family
card:y6
Aadhaar Ration
card:Expenditurefamily
Savings/Debts: Total
Animals/Pets:No
conditions
Economic HandExcreta RefuseUtensils:
age Purification: NatureSource
Boiling/Straining/
Filter/Purifier
Kitchen: No Roofing:Flooring: Area: Type:ENVIRONMENT
Kutcha/Pucca/Semi-pucca Housing
through Ventilation:
of Attitude
towardsjob:
pension: strain washing: persons
disposal:
disposal: of of (Sq.
Separáte/Living
Clean/Food supply:water:
Ño
PDs: due
Color/Services: on: 00
income: 35 Tiled/Cemented/Mud
Thatched/Tiled
Adequate
per
feet)
yos to Diet/Medical Withsoap/Without Covered
economic Household Continubus/Intermittent Mniorooms:2 \00
items
/
bins/Open
room/Outdoor
conditions:Gson,
cafe/Recreations/Education: latrine covered altu Inadequate
/RCC/Asbestos
and
soap/Before/Public lbont
dumping/House cow
126
Other asiss
N0
/Stove/Kerosene:
Gas/Cylinder
NO tank. nFuel:
Drains/Septic
latrine/Open Storage
Present/Absent
Overcrowding: Cross sheets dung
benefits eating/After
Biogas/LPG/Kerosene/0thers Adequate/Inadequate
Ventilation: Walls:
Mosquito/Rats/Others:
yQ3 of Lighting: Number
Collection/Others
from hica water: BNCk/Mud/Thatti Rented/OW
social Sugoheotl , ablution ansi\
Adeuate/Inadequate rooms:2 of

security:

NO

(fasting?):
CustomsNO Food eating
Habitoffoods
Fried Most
intake:No
Salt/Pickles/Papad Total In InFruits Protein
intakeCalorie
intake Others Evening
Dinner Lunch Brunch Breakfast Recordall TypeDIETARY
a a Timings
taboos:NO commonly
beliefs/Food typicaltypical
and Veg/Mi~ed
diet-of
vegetable
week, week, food HISTORY:
outside:No used and
/Chutney/Salty on on
oil: howconsumption
how drink (24
Vegetable Recommended Food hour
many many eaten
Coee items dietary
days days on
processed the
oil/Butter do do with recall
127 you you previous
quantity
eat eat method)
foods:
Frequency
week:per or I560 Actual
intake
ghee/Margarine vegetables fruit? day
No diet:ia
Jegghob
Staple
between

midnights
Days Calorie
/0ther: Deficit/Excess

Serving/
Amount
Protein
 Examination
Examination Central
Auscultation:
Percussion: Auscultation:
Cardiovascular
examination
Palpation: system
Inspection: Percussion: EXAMINATION
Palpation:
Inspection:
Respiratory
System Waist hygiene:God
Height:
b5Tongue/Oral Blood
SYSTEMICAnthropometry
cm se NomalSkin OrientationCalm, EXAMINATION
Temperature:
PulAne
examination: lsen
No\
JVP:
Patient'
condition
general
s
GENERAL
edema/Lymphadenopathy/Koilonychia:
Pallor/Icterus/FelCt delay
Radio-femoral
(carotid/brachial/radial/femoral/popliteal/dorsalispedis/posteriortibial) yanosi
Vessels/Clubbing/Built/Nourishment:
Pedal No
Nervous circumference: Pressure: equally rate, - conscious
wall
of rhythm, to
both of in thick time,
Abdomen: System eo and
all
knee
918 o (atherosclerosis)
(bperipheral volume cooperative:
place \a
examination: (relevant irhoo mmA
joints:
Sirontrd and bt
No person:
pulseRaquan.
8lmini
Noro)
first) Weight:6o
system Hip kg raaio (lm&
circumference: s
128 Respiratory
rate/Type:
\b\mih yeS palpation:
NoTma
Thyroid O
nonehad
feroal ohsouD
td
to
3HichWHR:
dlay platina
BMI:22

o
82Chora) 2ergon

Advice examination:
Followup
Treatment: COMPREHENSIVE vrdiieà FINAL Advised: Already LAB
INVESTIGATIONS examination:
PROVISIONAL
DIAGNOSIS: system
examination:
Other examination:
Breast Foot

on CLINICO-SOCIAL
self done:
care (A) abaosis
Maoruy
HyuDm Chs
MANAGEMENT
practices: First
DIAGNOSS
Atay
lina
Ari-tunslan PLANSis A
129 oaleî
d
a nae
ediassie
duqs cloie Mr.

dagiattihamg.hiO
ing
ih
g
o aUm
al
 COMPLAINTS
CHIEF 1
Pedigree Type SN
FAMILY Address:
Nearest
facility:
health
hmeunn
Religion:
Occupation:Gender:
Mle Aven
Mtthow
Name:
of Name
the DETAILSadrai
family:
chart of
family:
sex Age/
(Expand
Nuelear Relation
HOF to a INTEGRATED
if
/three more COMMUNICABLE
DISEASECASE
Marital
status fathiha
generation/ family
CLINICO-SOCIAL
130 members) olg
Education
Joint
Distance
Contact Caste:Income:
amsr.
Education Age: q
Occupation CASE
Motinou number:
in
STUDY
km:
Income
2\ns

Hoth Co
Hatiny statusHealth
hmih)

History of H/o HealthVaccination

Nature?
complications Relevant
status:
chemoprophylaxis: NoneFrequencyNumber Side TREATMENT
Screening Referral: Places symptom
which H/o
use effects presenting
illness:
Who education
of of of
other of consultations:of treatment/Type
noticed? family of HISTORY
follow-up/investigations drugs:
systems - made
seekhim
Drug member:one
How
consumption/Adverse
did of \
of
medicine treatment
it
manifest? consultation?
or :
131 non received/Treatment
What
prescribed
effect/Diet/Follow-up Describe
was
advised?
onset
drugs:
drugs and
progression
details
visits:

Dirgu in

Alo
 Postmenopausal
Regular
menarche:
Age at
MENSTRUAL Stress:
NO
PersonalityHistory
hogienennitoind
Hygiene:PNOTal Boweland average
Sleep/appetite: ConsumingYes/No,
anyes, using
If Currently
yes,If Currently
yes,
IfHISTORY QOL/Stress/Tension/Pain/Guilt:
PERSONAL HISTORY
PASTservices:
wage/work:
with Loss ofLossNutrition:
Satisfaction of
Extra
care: Treatment:
Travel:Consultationfee: eachIMPACT
Investigatíon: visit
For OF
DISEASE
or of mention
irregular drugNorol
bladder
habits: smoking
HISTORY Type:
bleeding: allergy/reaction:No alcoholic
botnamount
drink:
per mention duration:
smokelessany
cycles: Cmn any
ofrequency:
drink,
duration: tobacco
romo beer, tobacco
e products,
wine,
132 duration:ml, products
frequency:
or such
Duration
Age spirits?
as
[snuff,cigarettes,
of
attainment Yes/No
of chewing
each
bidI?
cycle: frequency:
of tobacco, Yes/NoI
menopause:

betel]: N

0CCUPATIONAL
ployment, HISTORY
previous:
Current
and Stigma:
No ATTITUDE
TOWARDS
DISEASE
Involvement Response with GocHISTORY
Societal/Neighborho0d
Participation
Impact Interaction
relations: SOCIAL Family IistFamily If HISTORY
relationships History HISTORY MARITAL
OBSTETRICS
AnyFAMILYinfertility:
G/P/A:
of HISTORY
Status/Duration:
Attitude ImpactResponse
whoEmotional
support:
Go Stress yes,
of other
of accompanies morbidities H/o give
toward disease of of
TB/DM/HTN/CHD/CVE/Kidney
on
details:
family
society
in in disease of family:
social
festivals/
society:c family member
reason present /complications
on NO
Inter-familialgroups: towards on to it
towards
and illness: marriages/social Intra-familial
hospital/getting affected
duration: person:Posite
Y''ot
illness:tiue
in
by
xertsrelationship: relationship:)io
family:
similar
133 drugs: diseases
No
activities:
Pras
illness: birth/Contraception:
Child
H/o MotFnS
asood
of No
exposure 3
ondo
to a aout
hazards:
ho hld chid

ondttio hooh.
 Olthrough
d Foodschemes
PDs:ys Welfare Family
Aadhaar
card:y
age
RationExpenditure
Savings/Debts: No Total conditions
Economic
Animals/Pets:N0 tchen: NatureSource No
HandExcreta RefuseUtensils:
KiPurification: of
Ventilation:Roofing:Flooring:Kutcha/Pccà
/Semi-pucca
Area: Type:
ENVIHousing
RONMENTAttitude
towardsjob:
pension: strain card: family washing: of of persons (Sq.
disposal:
disposal: Sepafate/Living
Clean/Food supply: water: TilAdeQuat
eperd/CThateehteched/ed/Mud feet)
Color/Services:Gron on:
income:
due
Diet/Medicat
Bokíng/Straining/
No to With Covered
Housetotd Conthuous/ borQrooms:2
economic I5 soap/Without items
000 bins/Open
room/Outdoor
Tiled/Inadequate
RCC/Asbest/ os 84,
latrine covered
(Yors)
care/Recreations/Eduation:
conditions: Intermittent Filter and
soap/Before /Public
dumping/House /Purifier cow
Chia,B0p
134
Other Adequate/Inadequate Crosssheets dung
Storage Ventilation:
Gas/Cylinder Aon latrine/OpenDrains/Septic Fuel: Present/Absent
Overcrowding:
eating/After Walls:
benefits
Biogas/LPG/Kerosene/Others
Mosquito/ of Lighting: Number
/Stove
collection/0thers water: Brick/Mud/ThattiRehted/Own
from oho, tank:o
Rats/Others:ablution
Yo 0apos
/Kerosene:
social
ol)
Adèuate/Inadequate of

security: rooms: 3
Go
No

Total Invegetable
InFruits
and Protein
intake Calorie
intake Others Dinner Evening Lunch Brunch midnight. Record
BreakfastTimings TypenIETARY
a a
typicaltypical of
all diet-
HISTORY:
week, week, food
Veg/Mized:
and
on on
howconsumption
how drink (24
Recommended Food hour
many many eaten
items dietary
days days on
with the
do do recall
135 you you quantity
previous
eat eat
method)
Actual
intake
42b5 1330
vegetables fruit? day Staple
diet:
between

2 Days 35 Calorie midnight

Deficit/Excess
05925
2 Serving/
Amount and
lH3. 13.3 Protein
 Cardiovascular system examination
foods: Inspection:
Salt/Pickles/Papad/Chutney/Saltyprocessed ghee/Margarine /0ther:
/Butter or
commonly used oil: Vegetable oil Palpation:
Most
Fried foods intake: Frequency per week:
Percussion:
Habit of eating outside:
Food beliefs/Food taboos:
AuSCultation: 2ha Nornhoasd
Customs (fasting?):
Central Nervous System examination:
GENERAL EXAMINATION
Patient's general condition etounishod
Built/Nourishment: edartlybut
(orscio , m Cooyernlive
cooperative:
Calm,conscious and l onortd Examination of Abdomen:
Orientation to time, place and person: edema/Lymphadenopathy/Koilonychia: No
Pallor/Icterus/Cyanosis/Clubbing/Pedal Thyroid palpation: Novmol
JVP: N o n
Skin examination:
Temperature: 98-8 orma Examination of both knee joints:
volume 10 g
Pulse -rate, rhythm,(atherosclerosis)
Vessel wall thick
Radio-femoral delay
Felt equally in all peripheral pulse
(carotid/brachial/radial/femoral/popliteal/dorsalispedis/posteriortibial) Foot examination:
Respiratory rate/Type:2liin
Blood Pressure: 1\0\o mm HA Aodeirotyotase
Tongue/Oral hygiene:Norrol
Breast examination:
Anthropometry BMI: n .
Height: 12 cm Weight: lb kg
Hip circumference: WHR:
Waist circumference:

SYSTEMIC EXAMINATION (relevant system first) Other system/local examination:

Respiratory System
Inspection: Trota in miolina
Palpation:

Percussion:

Auscultation: Nonmo veeulo brohh 0un hood.

136 137
PROVISIONAL DIAGNOSIS: INTEGRATED CLINICO-sOCIAL CASE STUDY
COMMUNICABLE DISEASE CASE
Nane: Age:
Gender: Education
LAB INVESTIGATIONS Occupation: Income:
Already done: W)b o u Religion: Caste:
Address: Contact number:
Advised: Nearest health facility: Distance in km:

FINAL CLINICO-SOCIAL DIAGNOSIS FAMILY DETAILS (Expand if more family members)

SN Name Age/ Relation MaritalEducation Occupation Income Health
sex to HOF status status

bock qoT Lhihn ha

COMPREHENSIVE MANAGEMENT PLÁN

Type of the family: Nuclear/three generation/ Joint

Follow up examination: Pedigree chart of family:

Advice on self care practices:

CHIEF COMPLAINTS

138 139
 INTEGRATED CLINICO-sOCIAL CASE STUDY
ANTENATAL CASE
Patient's details:
Name: Mis MargpkcorA
Age: 25 yeo Gender: forraa
Occupation: Houmeuoiçe Income:
Religion: irdu Caste: e
Address: \Jardiom Madura Contact number:
Nearest health facility: Vordiquo PHC Distance in km: 2rn
Planned/Unplanned/ Assisted pregnancy Obstetric formula: G2
LMP: 21l202 EDD: 9 lo \202
FAMILY PROFILE AND COMPOSITION (Expand if more family members)
Immuni
Relation Marital Occupa zation
SN Name Age Sex Education Income
to head status tion Status
(<5 yrs)
1
Aorun tendb M Mamied hst otacor 25 00
Noh Mamed gthsta toung
Virotth Soh 36M Moied rd
Araciale mactonig 15000
4
25F Mame oma toUTeuE Tà tatsn
5
Sogo ard 2
6

Type of the family: Nuclear/Three generation/ Joint

Pedigree chart of family:

CHIEF COMPLAINTS: (Refer annexure for detail)

hO presenting complaints: aiort ne to Uhe tospital gor Tott
utental dhct- n on b.q.2on
157
 *"Regarding Iron tablets, enquire about dose and duration, whether taking daily or
pregnancy:
History of present she confirm her
pregnancy? not, any side effects because of IFA supplernentation (Nausea; vomiting; loss of
When and where did appetite; change in the color of stools).
is registered?
Whether the pregnancy registration?: (Govt.,
Private,Both)
the place of Ask whether the antenatal mother has received advices regarding the
If yes, mention
Antenatal Visit details following:
Services Trimesters Advices received*
Treat received
Ante Investigations ment
Trime natal
Physical donet
Received 1t trimester Foie acid tabsho
examination
-sters visits Symptoms

Nasn 2nd trimester

Vomtng acid
2nd
wmtinA Ahtominal
3rd
Vomitig Susgt. Atoralys)Ton 3rd trimester
VOmitihg AbiCminat
mni NËs Sun
2nd i Hening
5rots
done "Ask regarding diet, rest, warning signs, birth preparedness, breastfeeding, safe
3rd
sex, HIV/ AIDs, JSY and contraception.
Have they experienced any of these warning signs during pregnancy?
5t If yes, mention the warning sign briefly
Fever > 24 hours: No Headache: No
Additional
visits Blurring of vision: NO Reduced foetal movements: NO
1S gt Gioutth &on/Tion Palpitations: No Easy fatigability: No
Nil
alcim Breathlessness at rest: No Pain in abdomen:1\0
Nil Atoorol
3rd 3rd
Vaginal bleeding: NO Watery discharge: No
Nil
4t
Generalized swelling of the body and puffiness of face:0.
50
o Whether it is a planned/unplanned pregnancy?:Ponns
o Do you have any gender preference? If yes specify.yo
Additional
visits Menstrual history:
Age at menarche: \2 rs
*Physical - Wt and BP, abdominal examination, specify any other examinations Regularity of the cycles::Relar /Iregular
done pertaining to symptoms Days of flow: das
**Investigations Hb, Urine albumin,sugar, microscopy, USG, serological tests Excessive bleeding/ctots? No
(blood group and Rh typing, VDRL, Hep-B, HIV and other tests Whether sheexperience pain during periods? das

158 159
 DIETARY HISTORY: (24 hour dietary recall method)
Duration of married life: 3y13
Marital history: Type of diet: Veg/Mixed Staple diet:
Record all food and drink eaten on the previous day between midnight and
Age at marriage: 22
Consanguineous/ Non-consamguineous marriage: Non midnight.
"
before pregnancy: Timings Food items with quantity
Contraceptive method adopted pregnancy: OYdOms Calorie Protein
method adopted before Breakfast
Type of contraceptive Side effects, if any: No Brunch
contraceptive: lwY
" Duration of use of Lunch
Previous Obstetric history:
registered? ye Evening
Whether previous pregnancy was Dinner
Postnatal
Baby
Antenatal Intranatal Others
Year and Mode and (Wt, gender,
place of Compli Compli Compli condition at
Order date of cations cations
delivery* cations birth) Actual Recommended
delivery
intake (For pregnancy addl. ) Decit/excess Advice
Ohgohgum |de ob Calorie intakeb20 2480 dagiat
2020 C-Sodian borar
Protein intake 5\22 68
Crana

Fruits and vegetable consumption Days Serving /

amount
In atypical week, on how many days do you eat fruits?
*Normal/LSCS, If LSCS, specify the indication In a typical week, on how many days do you eat vegetables 180
Past history: (Refer the annexure for details) CAD CY,Astha,7B Total

Personal history: (Refer the annexure for details) \aod die
Occupational history: (Refer the annexure for details)
Family history: (Refer the annexure for details) No lo
Family support: Whether she is supported by in laws, husband, her parents and
siblings?
Whoaccompanies her to hospital visits? tuDod
Does she experience marital discord/conflicts/domestic violence?
160
Salt/Pickles/Papad/Chutney/Salty processed foods
Most commonly used oil: Vegetáble oil/Butter or ghee/Margarine/Other:
Fried foods intake: No
niTN , qpl Habit of eating outside: Oho in a whila
If yes, frequency per week: Ors ih a ilg
Food beliefs/ food taboos: No
Customs (fasting?): No
Dietary changes: Special diets/ Diet restriction No
. If yes, specify reasons:
Any other customs/beliefs observed in the family? NO
Are they utilizing Anganwadi services? NO
161
 Customs observed
ENVIRONMENT Valagappu(Baby shower) ceremony? Ûe n 7n rot o ion
Housing Rented/Ow Birth preparedness:
Type: Kutcha/PultaSemi-pucca
Number of rooms: Mave you/family members decided the place of delivery? Vdano teri
Area: (Sq. feet) 150 Sq-f Brick/Mud/Thatti Uave you/family members arranged or decided the mode of transport? 0
dung Walls:
Flooring: Tiked/Cemented/Mud and cow Have you/ family mermbers arranged for money/Dona
Lighting: Adeuate/Inadeguate
Roofing: Thatched/Tiled/RCC)Asbestos sheets Have you/family members decided who will accompany to the hospital? uDbnà e
Cross Ventilation: Adequate/Inadequate Uave you/family members identified any blood donor for any unforeseen
Ventilation: Adeuate / Inadequate emergencies?
rooms: Z
Overcrowding: Present/Absent
No of persons per
Storage of water: nks
Source of water: Conovaion KNOWLEDGE ASSESSMENT
Nature of supply: Conttrúbus/ Intermittent Pre-lacteal feeds: roud ro De qisn
Purification: Boffing/Strafning/ Filter/ Purifier Importance of breast feeding:Knon
Biogas/LPG/Kerosene /0thers Duration of breast feeding: rrths aia
Kitchen: Separate/Living room/Outdoor Fuel: Supplementary feeding: kroun
Utensils: Chean Food items covered Drains/Septic tank: &pio tont Immunization:krovwh
coltection/Others
Refuse disposal: Covered bins/Open dumping/House Family planning: Korouyh
Excreta disposal: Household tatine/Public latrine/Open
GENERAL EXAMINATION
Hand washing: Wh soap/Without soap/Before eating/After ablution
Built/Nourishment:dly bui rouiehad
Animals/Pets: NO Mosquito/Rats/Others: Mosqt.
Calm, conscious and cooperative: yes
Assess risk of childhood injuries Orientation to time, place and person: oñansd
Flooring -first floor and above?N Nature of floor: Slippery/ Non slippery Pallor/Icterus/Cyanosis/Clubbing/Pedal edema/Lymphadenopathy /Koilonychia No
Sharp or projecting edges in the house:NO Fire/Stove/Hot objects: Not intash JVP: Not assn Temperature: Agila
Pulse - rate, rhythm, volume: 8bm
Power sockets, insect repellents, kerosene, medications etc., in reach of
Blood Presure: \20\H hm Ha Respiratory rate/type: 18\min Troan aoira
Overall cleanliness (indoor, outdoor): o n Hygiene: God
Oral cavity:Gon
Economicconditions Anthropometry
Total family income6 0CO Per capital income: s Boo Ht/Wt: b Om|B8 ta Thyroid palpation: omo
Varicose veins: No Son
Socio-economic status of the family (refer annexure): v o midàdie dacs Spine: NKho Noal
Breast examination: (Inverted nipple/Crusting/Soreness/Swelling/Tenderness)
Total expenditure on: Diet/Medical
care/Recreations/Education:Re.22,50 Abdominal examination: (relevant system first)
Inspection: Look for the following,
Savings: YegSn Debts: S Ration card: Color/ Services: Goh Shape of the abdomen: orgtadiaby Symmetry:rtron)
Family strain due to economic conditions: No Fullness of the ore'Presence of striae gravidarum: P
flanksRor
162 163
 Umbilicus: vSda
Presence of linea nigra: Skincondition of abdomen: Norha INTEGRATED CLINICO-SOCIAL CASE STUDY
Hernial orifices: Noal POSTNATAL CASE
Any scar if present: a hahn Sipubie
Patient's details:
Palpation NameDrorshini
Flanks: PutlEmpty Fundal height: 3b nss F\as qu Age: 13 r3 Gender: Fole
Look for the following grips, Occupation: tosTaie Income:
Fundal grip: bdst it indayenmblical gnp: o Sotth istaa
'pelvic ggetie s Religion: irda Caste:
1 pelvic grip: hood b h Address: odiorin Contact number:
grip: Type of presentatioh and lie offetus: (phalic Nearest health facility:
Position: Engagement: Nt arqg Distance in km: 12 Km
Auscultation
henbikomih
Planned/Unplanned/Assisted pregnancy
FHS: Site/Rate per minute: haosd bo0 Obstetric formula: Date of delivery: Place of delivery: vlaal
Respiratory System FAMILY PROFILE AND COMPOSITION (Expand if more family members)
Inspection:
Normal Voioul broth g0undo haod Relation
Immuni

Palpation: SN Name Age Sex

Marital
Education Occupa Income
zation
Percussion: to head status tion Status
Auscultation: (<5 yrs)
Cardiovascular system examination 1 agitgrda Heod gsWol Moni BE Anatb151000
Inspection:
Palpation:
Percussion: 3P
4 Raarmta0
Auscultation:
Comment on 5Mgron Votnso 5o gs Rab anied reds
Heart sounds: S, iSg hond Additional sounds: JOna 6
Murmurs: No Pericardial rub: (Pericarditis) No
Central Nervous System examination
LAB INVESTIGATIONS Type of the family: Nuclear/Three generation/Joint
Already done: Pedigree chart of family:
Advised:
CLINICO-SOCIAL DIAGNOSIS MYS-Maropori, 2 r od Hon adiqu mouo

COMPREHENCNrCAEL=3HO.. CHIEF COMPLAINTS: (Refer annexure for detail)

MANAGEMENT PLÀN Ask about the following, signs and symptoms of post partum haemorrhage, pre
eclampsia/eclampsia and infection (Refer annexure for details to be asked)
Potiert ume gor eaqe onginarmant Thegnatey
roOtnirgin
Follow up examination:

38cieion ste enitotion 165

 History of presenting illness:
Totient 000 yayaty romal taY baae hon hs
She aama to the ospit or de ninsmert
Theqnarog
History of present pregnancy:
When and where did she confirm her pregnancy? n Oh H6th
nsronhaa.
Whether the pregnancy is registered? 4es
If yes, mention the place of registration? (GOvt., Private, Both)
Antenatal Visit details

Ante
Trime
natal Treat Services
-sters Investigations received
visits
Symptoms Physical done** ment
***
examination* Received
1

1S 2nd

3rd

2nd

2nd
3rd Adoirol
|CGtst
5t

Additional
visits
1st

2nd
3rd 3rd

4th

5t
Ardotriral
Addivisitstional

166