CLINICO-SOCIAL CASE REVIEW

GERIATRIC CASE
Dr. Saurav Basu (Senior Resident)
Dr. Rahul Kumar (Post Graduate Resident)
IDENTIFICATION DETAILS
Name- Age-
Education- Religion-
Occupation-
Total number of family members:
FAMILY DETAILS
SN. NAME RELATION AGE SEX OCCUPATI EDU
SHIP ON STATUS
WITH THE
PATIENT
 CLINICAL HISTORY, GENERAL, AND SYSTEMIC EXAMINATION
OF THE INDEX CASE

• Any Presenting Complaint:

• History of Present illness:

• Past history: h/o bowel/bladder complaints, h/o gait

disturbance, h/o memory problems

• Treatment History: (on medication for ?DM/HTN)

• Family History

• Socioeconomic Status
 DIETARY HISTORY- 24 hour Dietary Recall
TIME FOOD ITEM AMOUNT CALORIES IN PROTEINS
KCal IN GRAMS

TOTAL CALORIES = /day

TOTAL PROTEIN=

Recommended calorie intake - kcal/ day

Recommended protein intake – g/day

Calorie deficit= Present/Absent

PERSONAL HISTORY
•Type of diet
•History of drug allergy
•Addictions (tobacco, alcohol)
•Sleep quality
ENVIRONMENTAL HISTORY

•The family resides in a kaccha house with two living room and attached toilet.
•Lighting and ventilation are adequate/inadequate.
•Overcrowding is present/absent as per __________ criteria
•Vector breeding sites, and the presence of vectors
•Source of drinking water, and storage
•Indoor household environment and safety against falls
- Railing in stairs
- Non slippery tiles
- Adequate lighting especially night light
- Rods in bathrooms
- Absence of obstacles
Health Seeking Behavior
•Allopathy/AYUSH, government/private
•Health Insurance, etc

Socio-cultural History

• Relationship with family members, neighbors

• Does he have friends?
• Does he have hobbies?

• Social security: Pension/support from family members

•EXAMINATION:
•Orientation in time, place, person
•Height – ……cm
•Weight: ….. kg
•BMI:_____
•Pallor-
•Icterus-
•Cyanosis-
•Clubbing-
•Pedal edema-
•Lymphadenopathy-

Vitals
Temperature-
BP-
Respiratory rate-
Pulse Rate-
Systemic examination:
•Respiratory system:

•Cardiovascular system:

•Central Nervous system:

•Eye Examination:

•ENT Examination:

•Skin problems
FOR FUNCTIONAL ASSESSMENT:

•ACTIVITIES OF DAILY LIVING

•INSTRUMENTAL ACTIVITIES OF DAILY LIVING

FOR MENTAL STATUS:

•MINI MENTAL STATE EXAMINATION?

•DEPRESSION?
CLINICO SOCIAL DIAGNOSIS

Mr ………. , …….. year old Resident of Delhi, living in a …..member

______family ,_____ by religion belonging to _________ of socio
economic status, with ? Clinical diagnosis and duration