Clinico-social-case format (Index case- Geriatrics)

1. Identification & demographic details:

Name: 

Age: 

Sex: 

Religion and caste:

Education: 

Occupation:

Marital status: 

Address: 

Nearest health facility: 

2. Presenting/ Chief complaints:

Complaints of____________since______days/ months/ years. (In chronological order)

3. History of presenting 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). There is no history of _______________________. (Ask & write the negative history based on probable causes.)

4. Past history: 

Write down if any history of past surgeries, illnesses, blood transfusions, allergies, or trauma.

5.Marital, Menstrual & Significant obstetric history: 

(if female patient)

Married since____________years/months

Age of menarche___________years

Menstrual cycle: Regular/ irregular

Passing clots: Yes/ No

Menopause attained: Yes/ No

Number of children:_____________

Mode and place of delivery of each child:_______________

Regular ANC taken in all pregnancies: Yes/ No

6. Personal history:

Diet: Veg/ Mixed/ Vegan

Appetite: Normal/ Increased/ Decreased

Bowel & bladder: Regular/ Irregular

Sleep: Normal/ Increased/ Decreased

Physical activity: Sedentary/ Moderate/ Heavy worker

Addiction: Yes/ No

(If yes, then specify Gutkha/ Pan-mashala/ Tobacco chewing/ Smoking/ Alcohol/ IV drugs)

7. Family history: 

Family type: Nuclear/ Joint/ 3 generation

Family composition (draw a family tree)

Any history of consanguinity: Yes/ No

Family relationships: Good/ Not good

The response of family towards the illness:_____________

(No need to write if it is included in the family details)

8. Environmental history:

Housing:

Toilet:

Waste disposal:

Drinking water:

Animals/ pets:

Occupational environment:

(No need to write if it is included in the family details)

9. 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)

10. Nutritional history (as relevant to the case):

Calculation of calories, carbohydrates, proteins & fats (& salts) being supplied to the person by 24-hour diet recall method (tabular format for breakfast, lunch, evening snacks & dinner) and required amount by the person through diet. Mention the deficiency or excess.

(No need to write if it is included in the family details)

11. Psychosocial history:

Mental changes: Memory loss/ Depression/ Any other______

Living with: Spouse/ Son/ Daughter/ Relative/ Others

Emotional disorders: Loneliness/ Feeling unwanted/ Insecurity/ Other________

Activities of Daily Living (ADL):

Toileting: Yes/ No

Bathing: Yes/ No

Dressing: Yes/ No

Eating: Yes/ No

Moving around: Yes/ No

Voluntary control over urine & fecal discharge: Yes/ No

Transferring to and from the bed: Yes/ No

Instrumental Activities of Daily Living (IADL):

Light housework: Yes/ No

Preparing meals: Yes/ No

Taking medicines: Yes/ No

Shopping: Yes/ No

Using telephone: Yes/ No

Managing money: Yes/ No

12. General physical examination:

Vitals:

Blood pressure (BP): ___________ mm Hg, 

Pulse rate(PR): __________ beats/ min

Respiratory rate (RR): __________ cycles/ min

Temperature: ___________ degree F

Pallor: Yes/ No

Icterus: Yes/ No

Clubbing: Yes/ No

Cyanosis: Yes/ No

Lymphadenopathy: Yes/ No

Edema: Yes/ No

Anthropometry: 

Built: 

Nourishment:

Height: _________m

Weight: ________kg

BMI:__________ kg/ m2

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

Any other significant finding____________________

13. Systemic examination:

Respiratory system:

Inspection:

Palpation:

Percussion:

Auscultation: 

Cardiovascular system:

Inspection:

Palpation:

Auscultation: 

Gastrointestinal system:

Inspection:

Palpation:

Percussion:

Auscultation: 

CNS examination:

Inspection:

Palpation:

Musculoskeletal system: 

Inspection:

Palpation:

Provisional clinical diagnosis:

Laboratory investigations:

(already done and planned in future)

Clinico-social diagnosis:

This is the family of Mr.____________residing in ________ (name of the area), having 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?)

Comprehensive management plan: