Dr Neelam Sukhsohale, AP, GMC AKOLA

Epidemiological Case History (Objectives)

1) Establish Diagnosis
2) Identify cause of illness / disease
3) Treatment
4) Tracing the source of infection in infectious cases & risk factors in non-communicable diseases
5) Identify Medical, Social, Cultural, Environmental, Psychological & Behavioral causes of illness in
an individual, his/her family & community
6) To carry out or implement Preventive & Control measures at Individual, Family & Community
level so as to prevent spread of infection& recurrence in communicable & non-communicable
diseases.

INDIVIDUAL CLINICAL CASE

A --- year old male/female patient by name ---------(born out of consanguineous /non-consanguineous
in case of children) residing at -------, -----by religion, ----by caste, educated up to----, ----by
occupation, was admitted through OPD/Casualty in ward no. ----- bed no. on-----at-----am/pm with
chief complaints of ------
Nearest health facility & distance from health care facility
• Chief complaints in chronological order (Patient’s words)
• 1.
• 2.
• 3.
History of present illness (Patient’s words)

Patient was relatively alright ---- days/months back.

A chronological description of the development of the patient’s present illness from the first sign
and/or symptom, or from the previous encounter to the present usually stated in the patient’s words.”
include following elements: Onset, location, quality, severity, duration, timing, progression, context,
modifying factors and associated signs and symptoms, contact history (source of infection)

Negative history: (Patient’s words)

Past Medical / Surgical History

• H/o similar complaints in the past

• H/o Medical / Psychiatric Illnesses
• 1. Diabetes
• 2. Hypertension
• 3. Tuberculosis
• 4. COPD (Bronchial asthma, Chronic bronchitis, bronchiectesis, emphysema)
• 5. STD/HIV AIDS (High risk behaviour)
• 6. Jaundice, Depression
• H/o Allergies and Reactions to Drugs
• Current Medications (Including "Over-the-Counter")
Surgeries /Injuries /Hospitalizations / (Appendisectomy, Car Accident, etc.) Blood transfusions

Family History
• Type of family: Nuclear, Joint, Three generation
• No. of Family members:

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 • Family composition: Draw a family tree
• Similar complaints / illnesses in the Family or other major illnesses/hereditary diseases e.g.
TB, DM, HT, IHD, cancers, genetic disorders

Personal History
 Addictions - Alcohol, smoking, tobacco, Other drugs etc,… (duration, quantity, frequency)
 Sleep and Rest
 Bowel and Bladder habits
 Diet : Vegeterian / Mixed diet / Vegan
 H/o Contraceptive practice in female patients {OC pills, i pills, IUCD (Cu T)}

Physical activity

Sedentary activity : e.g. Managers, executives, officers

Moderate activity : e.g. Housewives looking after grown-up children, tailors

Heavy activity : e.g. Housewives looking after small children, laborers, farmers, rickshaw-pullers

SOCIO-ECONOMIC HISTORY

Interaction with society: Yes/ No

The response of society towards the person: Good/ Bad/____
Presence of stigma: Yes/ No if yes specify____________________
Participation in festivals, marriages and other social activities & involvement in social groups: Yes/ No
Total family income:______________
Expenditure on diet and medical care:____Savings or debts_____________________
Family tensions due to the economic situation:Yes/No (No need to write if it is included in the family
details)
Social welfare measures: PDS/ JSY/ Anganwadi/ others__________

URBAN AREAS: Modified Kuppuswamy scale :Based on 3 components 1) Education of head of

family 2) Occupation of head of family 3) Monthly family income in Rs/-

RURAL AREAS : Prasad scale Based on Per capita income

Modified Kuppuswamy scale scoring for urban areas is as follows - (Updated for 2017)

Education of head of Score Occupation of Score Family income per Score

family head of family month in Rs/-

Illiterate 1 Unemployed 1 ≤ 2242 1

Literate less than middle 2 Unskilled 2 2243 - 6662 2

school certificate worker
Middle school certificate 3 Semi-skilled 3 6663 - 11103 3
worker
High school certificate 4 Skilled worker 4 11104 - 16656 4

Higher secondary 5 Arithmetic skill 5 16657 - 22208 6

certificate jobs
Graduate degree 6 Semi- 6 22209 - 44417 10
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 professional

Postgraduate or PG degree 7 Professional 10 ≥ 44418 12

1. Upper class (I) = 26 - 29

2. Upper middle (II) = 16 – 25
3. Lower middle (III) = 11 – 15
4. Upper lower (IV) = 5 – 10
5. Lower (V) = <5

Prasad Scale (Updated for 2016)

• Social class Per Capita Income

• Class I Rs ≥ 6346
• Class II Rs 3173 - 6345
• Class III Rs 1904 - 3172
• Class IV Rs 952 - 1903
• Class V Rs < 951

Modified BG Prasad’s Social Classification : Used for both Urban & Rural areas

Prasad’s Social classification (1961) Revision of the Prasad’s social classification for the
year 2020
Social Class Per capita monthly income Social class Revised for 2020
limits (in Rs./.month
I 100 and above I 7533 and above
II 50-99 II 3766 - 7532
III 30-49 III 2260 - 3765
IV 15-29 IV 1130 - 2259
V Below 15 V 1129 and below

Psychological history (H/o mental stress: Financial, Exam stress, emotional, death of relatives)
Mental changes: Memory loss/ Depression/ Any other______
Living with: Spouse/ Son/ Daughter/ Relative/ Others
Emotional disorders: Loneliness/ Feeling unwanted/ Insecurity/ Other________

Social history : Social factors eg Social evils, quality of life, quality of living

DIETARY HISTORY By 24 hour recall method OR Hospital diet OR Routine diet

• Beverages (Tea/milk/coffee )
• Breakfast
• Lunch
• Dinner
• Snacks, fruits etc in between ____________________ Others (specify)_____________

Calculate: Calories (kcal) / day and Proteins (gms)/day

Calories ( kcal ) Proteins ( gms )

3
Requirement

Intake

Deficit
• Women Men

• Sedentary work : 1900 2320

• Moderate work : 2230 2730

• Heavy work : 2850 3490

Deduction in calories > 40 years

• 40 – 49 years -- 5 %
• 50 – 59 ,, -- 10 %
• 60 – 69 ,, -- 20 %
• 70 – 79 ,, -- 30 %
• 80 – 89 ,, -- 40 %
• 90 – 99 ,, -- 50 %
Environmental History

• Type of house : kaccha/ pucca

• Type of roof / floor / walls : Made up of mud /cement /stone / tin / thatched

• No. of rooms/ doors/ windows

• Overcrowding: no. of persons per room

• Lighting : well aerated, well lighted or not

• Ventilation : cross ventilation present/ absent,

• Kitchen : type of cooking fuel à LPG / Chulha / Kerosene stove/ Gobar gas/ mixed fuel

• Source of drinking water : Tap / well / hand-pump

• Water Supply : continuous (24 hrs/ intermittent ) storage of drinking water: steel utensil,
matka

• Drawing water – mug with handle/ without handle

• Method of purification of water (Household level): boiling/straining/disinfection/UVR/filtration

• Storage of perishable & non-perishable foods

• Presence of separate latrine & bathroom: if yes, type of latrine ;

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 • if no, open air defecation – at what distance from the house

• Drainage : liquid drainage and solid drainage

• Garbage disposal /collection : daily, weekly …etc

• Pet animal : in c/o dogs à immunized/not

• Insect / Rodent Nuisance

• Courtyard of house : surroundings clean/not

• Peri-domestic collection of water

• Personal hygiene /community hygiene

• Occupational environment:

Treatment history: From records

General Physical Examination

• Patient is ----obese/moderately/average built/ thin, well-nourished, conscious, cooperative, well

oriented with time, place and person , comfortably lying /sitting in bed

• Patient is febrile / afebrile Temperature: _____degree F

Anthropometry:
Built: Nourishment: Height: ____m Weight: ________kg
Body mass index BMI:(Quetlet index)__________ kg/ m2
Hip circumference : Waist circumference: Waist-hip ratio :
Pulse Rate :---beats/ min regular/ irregular, rhythm, volume, character, peripheral pulses
Resp. Rate : ---cycles/ min, regular / Irregular, thoraco-abdominal / abdominal
Blood Pressure (BP) -----mmHg------right/left arm in ----- sitting/ supine position
Pallor / JVP / Clubbing / Icterus / Edema / Cyanosis / Lymphadenopathy etc,

Head to toe examination

General cleanliness: Good/ Bad Hair: clean/Unclean/ Combed/ Uncombed
Eye: Vision: Normal/ Decreased; Using spectacles: Yes/ No; Senile cataract: Yes/ No/ Mature/ Imature;
Glaucoma: Yes/ No; Operated: Yes/ No
Ear: Hearing: Normal/ Decreased; if decreased ,type of hearing loss: Conductive/ SNHL/ Mixed; Ear
discharge: Yes/ No
Oral: No of teeth:______; Using dentures: Yes/ No; Oral hygiene: Good/ Poor
Thyroid swelling: Yes/ No Breasts: Normal/ Abnormal________
Any other significant finding____________________

Systemic Examination
Respiratory system:
Inspection: Palpation: Percussion: Auscultation:
Cardiovascular system:
Inspection: Palpation Auscultation:
Gastrointestinal system:
Inspection: Palpation: Percussion: Auscultation:
CNS examination:
Inspection: Palpation:
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Musculoskeletal system:
Inspection: Palpation:
Genitourinary
Neurologic / Psychiatric
Skin / Breast
Eyes / Ears / Nose / Mouth / Throat
Allergic / Immunologic /Lymphatic / Endocrine
Provisional Clinical Diagnosis :

Final Diagnosis:

Investigations performed / advised : Hb%, CBC, Urine routine & microscopy, Urine albumin, USG, Viral
markers, Blood grouping & Rh typing, KFT, LFT, Lipid profile, Thyroid profile, Blood sugar-FBS, PPBS,
Pap smear test, etc. (already done and planned in future)
Management / Treatment :
Control and Preventive measures at Individual, Family & Community level
Health seeking behaviour
Medico-social problems in given case :
Positive risk factors :
• Advice given :
• Follow up :
At the end of history taking, be prepared with the positive findings (in history taking – chief
complaints, past history, family history, personal history, environmental history, psychosocial history,
dietary history----etc ) general & systemic examination) or positive risk factors present in your
patient.

ANC CASE
• A --- year old female patient by name ------residing at ------, -----by religion, ----by caste,
educated up to----, ----by occupation, was admitted through OPD/Casualty in ward no. -----
bed no. on-----at-----am/pm with H /o amenorrhea since .……weeks of gestation preferably
(not months)

• Presenting /Cheif Complaints:

• H /o present illness :My patient was apparently alright then he developed _____________(name of
the symptom) which was insidious/ sudden in onset, progressive/ non-progressive in nature.
(describe each symptom in detail with treatment history if taken).

• Negative history to rule out high risk pregnancy

• H /o present pregnancy :

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 • She is a Registered / Booked case of pregnancy yes/no

• If yes, name of the hospital, gestational age at which registered

• 1. Time of registration________(in months)

• 2. Confirmation of pregnancy: UPT at home/ a health center/ other

• 3. Source of Antenatal care__________

• 4. No. of Home visits__________5. Antenatal period____________

Significant events occurred in

 1st Trimester (first 12 weeks)

 Registration details_____________
 Excessive vomiting: Yes/ No
 Bleeding p/v: Yes/ No
 Fever with rashes: Yes/ No
 Drug intake: Yes_______________________/ No
 Weight gain: __________Kg
 Investigations-Hb%, CBC, Urine routine & microscopy, USG , blood grouping & Rh typing, VDRL,
HBsAg, HIV, RBS, Lipid profile, Thyroid profile (TFT), LFT, etc.
 Folate supplementation: Yes since______/ No
 TT: Taken/ Not taken/ 1st dose/ Both doses

2nd Trimester (13 – 28 weeks)

 Quickening: Felt at_________ weeks/ Not felt
 Weight gain: Yes__________Kg/ No
 Blurring of vision: Yes/ No
 Epigastric pain: Yes/ No
 Pedal edema: Yes/ No
 Headache: Yes/ No
 Iron and calcium supplementation: Taking daily OD/ BD/ No
 Side effects because of IFA supplementation: Yes Nausea/ vomiting/ loss of appetite/ change in
the colour of stools/ No
 Hours of sleep/rest: Afternoon___hours and night___hours
 Tetanus toxoid immunization: Yes 1st dose/ 2nd dose/ No
 Investigations: Hb%, CBC, Urine routine & microscopy, Blood suger-FBS & PPBS, USG Abdomen,
LFT, KFT, Lipid profile, Thyroid profile (TFT), etc.

3rd Trimester (29 – 40 weeks)

ANC visits: Yes ______times/ No
Weight gain: Yes_____Kg/ No
Warning signs: Present/ Absent
 Pain abdomen: Yes/ No
 Decreased perception of fetal movements: Yes/ No
 Leaking / Bleeding pv: Yes/ No
 Any high risk status: Yes_____________/ No
• Whether high risk / normal
• H/o TT immunization
• H/o hospitalization & T/t if any

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 OBSTETRICAL HISTORY G-P-A-L
Marital status :
Husband's name:Blood group & Rh type:
Age of marriage:_____________Years
Type of marriage: Consanguinous/ Non-consanguinous
Duration of active married life:____Months/ Years
Interval between previous & present pregnancy:_____months/ years
LMP:_______/________/________ EDD_______/_________/________
POG (Period of gestation):__Months
Sexually active up to:________Months POG
Registration of pregnancy done at:_______________(Name of place & date)

SN Year & Pregnanc Labour events, Method Puerpereu Baby (weight ,

date y events hosp/ home of m condition at
delivery birth )
1.
2.

Menstrual history : Age at menarche_____years, Age of 1st confinement , previous menstrual cycles:
duration, amount of blood flow, regular/irregular, passage of clots, Used_____Pads/day

Past Medical / Surgical History

• Past H/o Medical / Psychiatric Illnesses
• 1. Diabetes
• 2. Hypertension
• 3. Tuberculosis
• 4. COPD (Bronchial asthma, Chronic bronchitis, bronchiectesis, emphysema)
• 5. TORCH infections/STD/HIV AIDS
• 6. Jaundice, Depression
• 7. H/o Allergies and Reactions to Drugs
• 8. H/O Fever with rash: Yes/ No
• 9. Current Medications (Including "Over-the-Counter")
• 10. Surgeries /Injuries /Hospitalizations / (Apendicectomy, Car Accident, etc.) /Trauma/Blood
transfusions
Family History
• Type of family: Nuclear, Joint, Three generation
• No. of Family members:
Family composition: (draw a family tree)
Any history of consanguinity: Yes/ No Family relationships: Good/ Not good
• The response of family towards the illness: _______
• Similar complaints / illnesses in the Family or other major illnesses/hereditary diseases e.g.
TB, DM, HT, IHD, cancers, genetic disorders
Personal History
 Addictions - Alcohol, smoking, tobacco, Other drugs etc,… (duration, quantity, frequency)
 Sleep and Rest Normal/ Increased/ Decreased
 Bowel and Bladder habits : Regular/ Irregular
 Diet : Veg/ Mixed/Vegan
Appetite: Normal/ Increased/ Decreased
 H/o Contraceptive practice in (OC pills, i pill, IUCD) prior to pregnancy
Physical activity
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• Mild activity : e.g. Managers, executives, officers
• Moderate activity : e.g. Housewives looking after grown-up children, tailors
• Heavy activity : e.g. Housewives looking after small children, laborers, farmers, rickshaw-
pullers
•
SOCIO-ECONOMIC HISTORY : use Modified Kuppuswamy or Prasad scale

Social history / Psychosocial history :

Additional requirement for expectant mother

• Calories : + 350 kcal/ day and Proteins : + 15 g/day
DIETARY HISTORY By 24 hour recall method OR Hospital diet OR Routine diet
• Beverages (Tea/milk/coffee )
• Breakfast
• Lunch
• Dinner
• Snacks, fruits Others (specify )
Calculate: Calories (kcal) / day and Proteins (gms)/day

Requirement Calories ( kcal ) Proteins ( gms )

Intake
Deficit

Environmental History

• Type of house : kaccha/ pucca

• Type of roof / floor / walls : Made up of mud /cement /stone / tin / thatched

• No. of rooms/ doors/ windows

• Overcrowding: no. of persons per room

• Lighting : well aerated, well lighted or not

• Ventilation : cross ventilation present/ absent,

• Kitchen : type of cooking fuel à LPG / Chulha / Kerosene stove/ Gobar gas/ mixed fuel

• Source of drinking water : Tap / well / hand-pump

• Water Supply : continuous (24 hrs/ intermittent ) storage of drinking water: steel utensil,
matka

• Drawing water – mug with handle/ without handle

9
 • Method of purification of water: boiling/straining/disinfection/UVR/filtration

• Storage of perishable & non-perishable foods

• Presence of separate latrine & bathroom: if yes, type of latrine ;

• if no, open air defecation – at what distance from the house

• Drainage : liquid drainage and solid drainage

• Garbage collection :

• Pet animal : in c/o dogs à immunized/not

• Insect / Rodent Nuisance

• Courtyard of house : surroundings clean/not

• Peri-domestic collection of water

• Personal hygiene /community hygiene

• Occupational environment:

Treatment history

• From records

General Examination

• Patient is ----obese/moderately/average built/ thin, well-nourished, conscious, cooperative, well

oriented with time, place and person , comfortably lying /sitting in bed

• Patient is febrile / afebrile

• Height : Weight :

• Pulse :---/min rate, rhythm, volume, character, peripheral pulses

• Resp. Rate : ---/min , regular / Irregular, thoraco-abdominal / abdominal

• B.P -----mmHg------right/left arm in ----- position

Pallor / JVP / Clubbing / Icterus / Edema / Cyanosis / Lymphadenopathy etc,

Obstetrical examination

Auscultation: Fetal heart sound:_____beats/min

Important clinical findings: 1. 2.
• Inspection:

• Skin condition of abdomen : Linea nigra, striae gravidarum

• Presence of any scar marks (previous LSCS) Prominent veins: Present/ Absent

• Palpation

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 • Abdominal girth:____cm

• Symphysio-fundal height

• Height of fundus: whether corresponds to gestational age

• Palpation of foetal parts (lateral palpation)

Grips : Fundal grip:____________________________

Lateral grip:_____1st Pelvic grip:________2nd Pelwic grip:_________________
• Auscultation : FHS (FOETAL HEART SOUNDS)

Systemic Examination
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Neurologic / Psychiatric
• Musculoskeletal
• Skin / Breast
• Eyes / Ears / Nose / Mouth / Throat
• Allergic / Immunologic /Lymphatic / Endocrine

• Laboratory investigations adviced / done Ist thing : Pregnancy detection (UPT)

• 1. Blood for HB gm% 6. Sickling test

2. Urine: albumin, sugar, microscopy 7. RDT for malaria

3. Blood grouping & Rh typing 8. Hepatitis B surface antigen test

4. VDRL

5. Elisa – HIV / AIDS

Any special investigations if any (USG/CBC/Stool exam/LFT/KFT/TFT etc______)

Provisional diagnosis

Eg. ANC patient -------weeks of gestation with / without any risk with / without medical health
problems

Summary:
Mrs. X, -------year-old, married since------------, is currently in 1st/ 2nd/ 3rdpregnancy in -----weeks
of gestation with ------ such complaints (high risk or not) is planning for safe confinement in ______ center.
Positive and Negative Factors:________
Level of failures:________

16. Comprehensive Diagnosis/ Clinico-social diagnosis:

This is the family of Mr.____________residing in ________ (name of the area), having______membered,
nuclear/ 3-generation/ joint family, belonging to socioeconomic status class __________ according to
_____________ (name of the classification), a BPL/ APL card holder. The health problems, health demands
& health needs of the family are _______________________. (Disease with/without complication, Social
problem, Mental problems). The vulnerable individuals identified in the family are ________ (why are they
vulnerable?)
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Comprehensive management plan:
Advice to mother:
Health promotion: Health education, Diet, self-care, personal hygiene, mental preparation, child care,
breastfeeding, use of Anganwadi & social benefits, etc.
Specific protection: Td & IFA, calcium tablets/ vitamin with dose & duration
Early diagnosis: Warning signs/ Any other unusual symptoms
mental preparation, child care, breastfeeding, use of Anganwadi & social benefits, etc. Specific
protection: TT & IFA
Early diagnosis: Warning signs/ Any other unusual symptoms

Comprehensive management plan

Levels of Primary prevention Secondary prevention Tertiary prevention

Prevention (Health promotion & (Early diagnosis & treatment) (Disability limitation
specific protection) & rehabilitation)
Individual
Family
Community

PNC / LACTATING MOTHER

• A --- year old female patient by name ----------residing at -------, -----by religion, ----by caste,
educated up to----, ----by occupation, was admitted through OPD/Casualty in ward no. -----
bed no. on-----at-----am/pm. A ---------- duration of PNC delivered a M/F baby on date
_________by FTND or LSCS ---------

• Chief complaints (mother as well as baby)

• HOPI :

• Negative history :

• ANTENATAL HISTORY

• No. of ANC visits throughout pregnancy

• Any complications during pregnancy – high risk/normal

• H /o TT immunization, IFA tablets

• Any investigations (routine/special)

• Any drugs received : doses & duration

INTRANATAL HISTORY

Date of delivery/ abortion/ MTP: _____/_____/______

Place of delivery/ MTP: Home/ institutional (HSC/ PHC
/ CHC/ Private)
Type of delivery: Vaginal/ C-section/ Instrumental
Any complication : Yes/ No
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Excessive bleeding / delayed 2nd stage / foetal distress / maternal distress / cord prolapse
Attended by:________________ No.of days of hospitalization:______
• Type of delivery : normal / abnormal; if abnormal à indication
• Whether delivery conducted at Home/ institution
• If at home, whether by trained / untrained person
• Maturity : full term / preterm / post-term
Outcome of Pregnancy: Spontaneous Abortion/ MTP/ Stillborn/ Livebirth
• H /o birth trauma, asphyxia, delayed labour
POST-NATAL HISTORY
Sex: Male/ Female/ Third gender
Baby cried immediately after birth or not
If not ….specify the reason
• Birth weight
• Any significant events in post-natal period
e.g any congenital defects / Birth injury / any infection / feeding problems, Breast problems / time
of establishment of breast feeding <2hrs, 2- 6hrs, 6 - 12hrs, >12hrs
Colostrum : directly fed / expressed & fed / expressed & discarded / not fed

Frequency of feeding : on demand / time OR schedule:

Immunization History: verify records BCG OPV hepatitis B

Complications in mother:
H/o High grade fever
• H/o Abnormal discharge P/V or Abnormal bleeding P/V
• Pain / tenderness in lower abdomen
• Changes in colour, amount, odour of lochia
• Dysuria, frequency of micturition
• Signs of mastitis
• Prolapse, sub involution / retroverted uterus
Home visits during the postnatal period: Yes_____times/ No
Postnatal care

Mother Baby Remarks

Date Temperature Lochia Fundus Lactation General Cord Feeding Bowel
condition

Family planning:
 Do the couple know that it is possible to prevent or postpone pregnancy: Husband: Yes/ No; Wife:
Yes/ No
 Are they aware of any methods of preventing or postponing pregnancy: Husband: Yes/ No; Wife:
Yes/ No
 If yes, which method(s):_____________________

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 Attitude towards family planning: Husband Willing: Yes/ No;
 Wife Willing: Yes/ No
 Are they practicing any method: Yes/ No
 If yes, which method:__________
 If no, did they ever practice: Yes_________/ No
 Describe how they decided on a particular method and reason for changing if any___________
 Are they satisfied with the method used: Yes/ No
 If no, give reasons:_________
• Menstrual history
• Age at menarche, Age at marriage, Age of 1st confinement , previous menstrual cycles:
duration, amount of blood flow, regular/irregular, passage of clots

Past Medical / Surgical History

• Past H/o Medical / Psychiatric Illnesses
• 1. Diabetes
• 2. Hypertension
• 3. Tuberculosis
• 4. COPD (Bronchial asthma, Chronic bronchitis, bronchiectesis, emphysema)
• 5. STD/HIV AIDS
• 6. Jaundice, Depression
• H/o Allergies and Reactions to Drugs
• Current Medications (Including "Over-the-Counter")
Surgeries /Injuries /Hospitalizations / (Apendicectomy, Car Accident, etc.) Blood transfusions
Family History
• Type of family: Nuclear, Joint, Three generation
• No. of Family members:
• Family composition:
• Similar complaints / illnesses in the Family or other major illnesses/hereditary diseases
e.g. TB, DM, HT, IHD, cancers, genetic disorders
Personal History
 Addictions - Alcohol, smoking, tobacco, Other drugs etc,… (duration, quantity,
frequency)
 Sleep and Rest

14
  Bowel and Bladder habits
 Diet : Vegeterian / Mixed
 H/o Contraceptive practice in (OC pills, i pill, IUCD) prior to pregnancy
Physical activity
• Mild activity : e.g. Managers, executives, officers
• Moderate activity : e.g. Housewives looking after grown-up children, tailors
• Heavy activity : e.g. Housewives looking after small children, laborers, farmers,
rickshaw-pullers
SOCIO-ECONOMIC HISTORY : use Modified Kuppuswamy or Prasad scale
Social history / Psychosocial history :
Additional calories and proteins required during Lactation
Calories : 0 - 6 months à + 600 kcal /day 6 -12 months à +520 kcal/day
Proteins : 0 – 6 months à + 25 gms / day 6 – 12 months à + 18 gms/day
DIETARY HISTORY By 24 hour recall method OR Hospital diet OR Routine diet
• Beverages (Tea/milk/coffee )
• Breakfast
• Lunch
• Dinner
• Snacks, fruits Others (specify )
Calculate: Calories (kcal) / day and Proteins (gms)/day

Requirement Calories ( kcal ) Proteins ( gms )

Intake
Deficit

Environmental History
• Type of house : kaccha/ pucca
• Type of roof / floor / walls : Made up of mud /cement /stone / tin / thatched
• No. of rooms/ doors/ windows
• Overcrowding: no. of persons per room
• Lighting : well aerated, well lighted or not
• Ventilation : cross ventilation present/ absent,

15
 • Kitchen : type of cooking fuel à LPG / Chulha / Kerosene stove/ Gobar gas/ mixed fuel
• Source of drinking water : Tap / well / hand-pump
• Water Supply : continuous (24 hrs/ intermittent ) storage of drinking water: steel
utensil, matka
• Drawing water – mug with handle/ without handle
• Method of purification of water: boiling/straining/disinfection/UVR/filtration
• Storage of perishable & non-perishable foods
• Presence of separate latrine & bathroom: if yes, type of latrine ;
• if no, open air defecation – at what distance from the house
• Drainage : liquid drainage and solid drainage
• Garbage collection :
• Pet animal : in c/o dogs à immunized/not
• Insect / Rodent Nuisance
• Courtyard of house : surroundings clean/not
• Peri-domestic collection of water
• Personal hygiene /community hygiene
Treatment history: From records
Examination of PNC Mother
General Examination
• Patient is ----obese/moderately/average built/ thin, well-nourished, conscious,
cooperative, well oriented with time, place and person , comfortably lying /sitting in bed
• Patient is febrile / afebrile
• Height : Weight :
• Pulse :---/min rate, rhythm, volume, character, peripheral pulses
• Resp. Rate : ---/min , regular / Irregular, thoraco-abdominal / abdominal
• B.P -----mmHg------right/left arm in ----- position
Pallor / JVP / Clubbing / Icterus / Edema / Cyanosis / Lymphadenopathy etc,
• Breast ,, :
• Systemic ,, : RS, CVS, CNS, --------------
• Scars of LSCS, Episiotomy wound à healed/not
• Vaginal discharge : no. of pads soaked / day
• Lochia à Type, colour, odour, amount, frequency

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 • Uterine involution
EXAMINATION OF NEWBORN
• Anthropometry
• Weight (kg), Length (cm), Head circumference
• Mid arm circumference - MAC (cm) Chest ,,
General appearance, hair, face, eyes, lips, tongue, teeth, gums, skin, nails
• Any signs of prematurity
• Any congenital malformations / disorders
• Reflexes : Moro’s reflex, sucking reflex, rooting reflex, Glabellar reflex, grasping
reflex
• Developmental milestones :
• Motor, Language, Adaptive & Social milestones
• Recognizes mother, Social smile --------etc
• Systemic examination: RS, CVS, CNS,-----------
• Examination for BCG scar :
• Probable diagnosis ---------- days old PNC mother delivered normally / LSCS ,
Fullterm / Preterm / LBW, Live / stillbirth with ---- complications if any
• Investigations done / Advised :
• Advice to be given:
• Preventive & control measures:

HEALTH RECORD FOR UNDER 5

• Name of Informant (Mother / Father/ Guardian), Literacy status of Father, Mother:

• A --- year old male/female child by name ----------residing at -------, -----by religion, ----by
caste, studying in playgroup/anganwadi/prenursery---- was admitted through OPD/Casualty
in ward no. ----- bed no. on-----at-----am/pm with

• Chief complaints of ------

• HOPI

• Negative history

• Past medical / surgical history :

• H/o similar complaints in the past

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 • Repeated h/o Diarrhea / ARI, h/o Pica , worm infestation, ( h/o passage of worms in stools )
H/o childhood illnesses  measles, chickenpox, pneumonia ( ARI ), hepatitis, TB,
Poliomyelitis ------------ Prolonged drug intake / others

• H/o hospitalization, Surgeries, falls, accidents, blood transfusions etc

• H/o allergies and reactions to drugs

• Family history:

• Type of family: Nuclear, Joint, Three generation

• No. of Family members:

• Family composition:

• Similar complaints / illnesses in the Family or other major illnesses/hereditary diseases e.g.
TB, DM, HT, IHD, cancers, genetic disorders

• No. of siblings, presence of hereditary diseases, TB, DM, others

Family History

• Type of family: Nuclear, Joint, Three generation

• No. of Family members:

• Family composition:

• Similar complaints / illnesses in the Family or other major illnesses/hereditary diseases e.g.
TB, DM, HT, IHD, cancers, genetic disorders

Personal History

 Addictions - Alcohol, smoking, tobacco, Other drugs etc,… (duration, quantity, frequency)

 Sleep and Rest

 Bowel and Bladder habits

 Diet : Vegeterian / Mixed / Vegan

SOCIO-ECONOMIC HISTORY : use Modified Kuppuswamy or Prasad scale

Social history / Psychosocial history :

• Antenatal history :

• No. of ANC visits throughout pregnancy

• Any complication during pregnancy

• TT received : yes/no; if yes, dose

Drug received: doses & duration

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 INTRANATAL HISTORY

• Any complication :

Excessive bleeding / delayed second stage / foetal distress / maternal distress / cord prolapse /
any other

Delivery conducted at home/ institution

If at home, whether by trained/untrained person

Type of delivery: normal/ abnormal (LSCS/FORCEP)

• Maturity : full term / preterm

• h/o birth trauma / with asphyxia

• POST- NATAL HISTORY

• Post natal period : eventful / uneventful

• If eventful , then

• 1. congenital defect : if yes ; type

• Any infection Feeding problem

• If yes, cause . . . . .

• If no, time of establishment of breast feeding

<2 hrs, 2 - 6 hrs, 6 - 12 hrs, >12 hrs

• Colustrum: directly fed / expressed & fed / expressed & discarded / not fed

• Frequency of feeding : on demand / time schedule

• Growth Monitoring done: yes/ no if yes – whether confirmed from Growth chart

• Frequency _______;

Immunisation History : verify dates; write dates when received

BCG: Scar mark present or not OPV 0:

Hepatitis B 1 2 3 4 Rota 1 2

DPT 1 DPT 2 DPT 3 IPV 1 IPV 2

OPV 1 OPV 2 DPT 3

MR + Vit A ( 1 lac IU ) MMR

DPT b + OPV b + Vit A ( 2 lac IU ) DPT (5-6 years)

No of vitamin A doses administered :

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 Any other vaccine received (under 5 children): HiB / PCV / Varicella / Meningococcal +
Pulse polio immmunisation (PPI)

Developmental history :Milestones

Age at which various motor, language, adaptive, social milestones have been achieved.

• Period of infancy : any significant events

• Pre-school age: ,,

• Diet history : consumed during last 24 hrs

• Beverages, Breakfast, Lunch, Dinner, Others (specify)

Calculate: calories & Proteins gms / day & deficit Calories , Proteins

Requirement Calories ( kcal ) Proteins ( gms )

Intake
Deficit

 For 1st 10 kg - 100 kcal / kg/day

 For 2nd 10 kg - 50 kcal / kg/day

 Then for every next 10 kg 25 kcal ,,

Environmental History

• Type of house : kaccha/ pucca

• Type of roof / floor / walls : Made up of mud /cement /stone / tin / thatched

• No. of rooms/ doors/ windows

• Overcrowding: no. of persons per room

• Lighting : well aerated, well lighted or not

• Ventilation : cross ventilation present/ absent,

• Kitchen : type of cooking fuel à LPG / Chulha / Kerosene stove/ Gobar gas/ mixed fuel

• Source of drinking water : Tap / well / hand-pump

• Water Supply : continuous (24 hrs/ intermittent ) storage of drinking water: steel utensil,
matka

• Drawing water – mug with handle/ without handle

• Method of purification of water: boiling/straining/disinfection/UVR/filtration

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• Storage of perishable & non-perishable foods

• Presence of separate latrine & bathroom: if yes, type of latrine ;

• if no, open air defecation – at what distance from the house

• Drainage : liquid drainage and solid drainage

• Garbage collection :

• Pet animal : in c/o dogs à immunized/not

• Insect / Rodent Nuisance

• Courtyard of house : surroundings clean/not

• Peri-domestic collection of water

• Personal hygiene /community hygiene

Treatment history: From records

Examination of under 5

• General appearance : normal built / thin built / poorly built

• Hair : normal / lack of luster / depigmented thin & sparse / easily pluckable / flag sign

• Face : diffuse pigmented / nasolabial dyssebecia / moon face/ hypopigmented patch

• Eyes : conjunctiva – normal / dry on exposure for ½ min / dry & wrinkled / bitot’s spots /
brown pigmentation / angular conjunctivitis / pale conjunctiva. Cornea - normal / dry / hazy
& opaque

• Lips : normal / angular stomatitis / cheilosis.

• Tongue : normal / pale & flabby / red & raw fissured / geographic

• Teeth : eruption of teeth /mottled enamel / carries / attrition

• Gums : normal / spongy / bleeding

• Skin : Normal / dry & scaly / follicular hyperkeratosis / petechiae / pellagrous dermatosis /
flaky paint dermatosis / scrotal & vulval dermatosis.

• Nails : nail hygeine koilonychia

• Oedema : in dependent parts

• Rachitic changes : knock knees / bow legs / epiphyseal enlargement / pigeon chest

• Reflexes :

• Anthropometry :

• Wt (kg), Length / Height (cm), HC (cm)

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 • MAC (cm) CC (cm)

• Internal system : RS , CVS , CNS , P/A

• Provisional diagnosis :

• Lab investigations : Hb , stool , . . .

• Advice & Preventive & Control measures:

• Positive findings:

Weight
• At Birth : 3 kg
• Weight gain in 0-3monthsà 800-900 gm/month ( 30gm/day)
• 4 months – 1year à 40 gm/month
• Doubles  6 months - 6 kg
• 3 times  1 year - 9 kg
• 4 times  2 years - 12 kg
• 5 times  3 years - 15 kg
• 6 times 5 years - 18 kg
• 10 times 10 years - 30 kg
• 3 months to 12 months – (Age in months + 9 )/2
• 2 (age in years ) + 8 à 1- 6 yrs
• 3 (age in years ) à 7-12 yrs
Length

• At Birth : 50 cm
• 3 months : 60 cm
• 6 months : 65 cm
• 9 months : 70 cm
• 1 year : 75 cm
• 2 years : 90 cm
• Thereafter ↑es by 5 cm every year till the age of 10 years
• length (cm) = 6 (age in years) + 77
 2 - 12 years

Mid upper arm circumference

• At Birth : 10 cm
• 1 year : 16 cm
• 5 years : 17 cm
• Remains constant between 1-4 yrs
Head circumference
• At Birth : 35 cm
• 3 months : 40 cm
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 • 6 months : 43 cm
• 1 year : 45 cm
• 2 years : 48 cm
• 3 years : 49 cm
• 5 years : 50 cm
• 7 years : 51 cm
• 12 years : 52 cm
Chest circumference
At Birth : CC < HC
1 year : CC = HC
After 1 year : CC > HC

Upper segment-lower segment ratio

• Normal US / LS ratios
• At Birth : 1.7 : 1
• At 3 years : 1.3 : 1
At 7 years : 1 : 1
Thereafter : 1 : 1.1

For PEM / ARI (Under five children)

Anthropometric measurements
Observed Expected
1. Weight W/A
2. Length/Height H/A & W/H
3. MAC
4. Chest circumference
5. Head circumference
6. US: LS ratio
ANIMAL BITE CASE
History of animal bite if Dog / Cat; ask whether it is ( Pet / Street / Stray)
Rodents (rat / rabbit / mice)
Wild animals: Pig, Monkey, Jackal, Mongoose, Wolves, Fox, Horse, Tiger, Loin etc ----------
Time of bite / duration since bite
In c/o Cats / Dogs: Type - (Pet / Street / Stray) Provoked / Unprovoked bite
Ask Whether there was any oozing / bleeding from the wound
Whether the patient had applied anything (Chilli powder, turmeric, salt, oil, lime, Raw chewed
rice, Wheat flour, tea/coffee powder, soil, cow dung, herbal products ----------------- any
inanimate substances)
H/o Immunisation against Tetanus / Rabies in the past
H/o Immunisation in animals (Dogs) – If possible, verify from immunisation
card/Record/certificate
- In Children, ask about Primary Immunisation
- In female patients, ask about Pregnancy / Lactation
- In all patients, ask about Steroid intake, radiation therapy, alcoholism, immunocompromised
state, severe malnutrition

General Examination:

Systemic Examination:

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 Local Examination :

- Anatomical site of bite, No. of bite marks

- Observe wound – type (abrasion, scratch, punctured, Lacerated CLWs ) & presence of
redness, oedema, ulceration etc

Diagnosis : Category ….I / II / III bite by WHO Classification

Treatment:

1. Local Cleaning of the wound: Soap & water, spirit, dettol, savlon…….other disinfectants

2. Inj TT 0.5 ml deep IM over deltoid in adults & over anterolateral aspect in children

3. ARV (CCV) Inj Rabipur (1 ml), Inj Verorab / Abhayrab/ Indirab ( 0.5 ml ), IM on days 0, 3, 7,
14, 28  post exposure prophylaxis – WHO ESSEN SCHEDULE

ID Schedule :

Available in ARV OPD  ? Inj abhayrab 0.5 ml

CATEGORY III BITES

In all Category III bites, Immunoglobulin ie Inj Equirab – 40 IU / kg BW (5 ml = 1500 IU)

- If Dog is observable, observe the dog for 10 days & follow up SOS

Antibiotics: Cap Ampicillin 500 mg qid / T. Septran ; Painkiller ; Antacids

Diabetic diet chart

 Morning – 7 am à 1 cup tea/cofee/milk/lemon water (without sugar/cream) + 1 marie biscuit

 Breakfast – 8.30 am – 3-4 slices wheat bread (Brown bread) / 3 chapati/vegetable/ 1 glass
oats/wheat flakes/broken wheat (dalia)/ 2 katori sprouts/2 katori upma/poha / boiled egg (white) /
soyabean milk plain or skimmed milk

 Madhyanha alpahar – 11am – 1 fruit (100gm) – preferably citrus fruits – oranges, guava, sweet
melon, grapes, awla lemon / 1 glass chash (butter milk) / 2 marie biscuits
 Lunch – 1.30 pm – 4 rotis (fulkas) + 1 katori rice/dalia, 1 katori green veg (less oil)
 1 katori dal /sprout green gram/chana/barbati/moth
 1 katori curd, salad (tomato/cucumber/raddish/cabbage)
 Afternoon breakfast – 4.30 pm: 1 cup tea/cofee/milk/lemon water (without sugar/cream) + 2
marie biscuit / dhokla/khandvi/ 25 gm murmura/chana/popkorn/lahi (rajgira/dhan) chana jor/1 piece
khakra/brown bread/veg sandwhich/ ½ plain rava dhosa/chila/1 pc rava idli sambar
 Evening snacks:1 fruit (100 gm)/ 1 glass chash

 Evening dinner: 8 pm : mix veg soup (without butter/maida/cornfloor) – salad

 4 roti , 1 katori rice/gruel/dalia
 1 katori green veg + 1 katori dal/kadi
 Before sleep – 10 pm – 1 glass milk / 1 fruit (100 gm)
 Water – 10-12 glass daily
 Daily brisk walking 40-50 min

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 Cooking oil – 500-750 ml/month
 Methidana powder before 30 min of meal
 Small frequent meal – 3-4 hourly
 Avoid – sweets, vanaspati ghee, red meat, 5 white products (refined rice/flour, white bread,
salt, sugar, sago) No fruit juices (except citrus fruits without sugar) or cold drinks
 Less quantity – refined foods such as Rice, fish, oil, ghee, butter, cheese, potato, arbi, suran,
shalgam, carrot, sweet potato, crystal sugar or trans fatty acids (deep fried foods – 6 Ps puri, pakoda,
paratha, papad, paneer, pizza, etc pedha )
 Coconut water, rice/dal water, lemon water ----- can be consumed lavishly
 Ashguard juice, fenugreek seeds, ……………….useful for Diabetic patients

Name Ingredients Calories Proteins

Hyderabad mix Roasted whole wheat 330/86gm 11.3/86gm

40 gm, Roasted Bengal
gram 16 gm, Roasted
Ground nut 10 gm and
Jaggery 20 gm

Besan mix Bengal gram flour, 500/100gm 9/100gm

wheat flour, jiggery,
ghee(1 part each)

Sooji mix Toned milk 750ml, 1432 28.4

sugar 100 gm, sooji 25
gm, oil 5 gm, water
1000ml

Shakti ahar Roasted wheat 40 gm, 390/100gm 11.4/100gm

roasted gram 20 gm,
roasted peanut 10 gm,
Jaggery 30 gm

Nutritive values in terms of calories and proteins

Preparation Quantity for one Calorie (kcal) Protein (gm.)
serving

Rice 1 cup 170 4

Phulka 1 No 80 2

Paratha 1 No 150 5

Puri 1 No 100 1

Bread 2 slices 170 4

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Poha 1 cup 270 5.8

Upma 1 cup 270 6

Idli 2 No s 150 4

Dosa 1 No 125 2

Khichidi 1 cup 200 8

Plain dhal ½ cup 240 12

Sambhar 1 cup 110 4

Boiled egg 1 no 90 6

Omelette 1 no 160 11

Mutton 8 bits(1 Oz) 50 6

Fish fried 2 big pieces 220 12

Vada 2 no 180 2

Potato bonda 2 no 200 2

Samosa 1 no 200 5

Chikki 2-3pieces 290 8

Tea 1 cup 75 0 to 20.21 g

Coffee 1 cup 110 0

Cow’s milk 1 cup 180 6

Buffalo’s milk 1 cup 320 9

Biscuit 1 No 32 0.4

Vegetable cooked 1 katori 79 2.0

Leafy vegetable 1 katori 80 3.0

Cooked potato 1 katori 142 1.6

Vegetable salad 1 plate 25 2.0

Mutton curry 1 plate 266 18.5

Chicken/ fish curry 1 plate 177 25.1

Paneer 11/2 cube 85 6.1

Reference: Parke’s Textbook of Preventive and Social Medicine, Elizabeth KE Nutrition and Child
Development, j Kishore, practical and viva for community medicine.
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