INTRO clincosocial importance .by xxxxxx

Community medicine

1. Introduction to CLINICO –SOCIAL CASE STUDY PRESENTED BY FACULTY : Professor Dr.Uma Maheswari Assistant professor Dr. Arvinth Ram PG :Dr.Oshin Lavanya 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 1

2. Clinico Social case study The approach of studying a disease process and managing the patient in its own environment is called clinico -social case study. Study the case in the light of the family and physical and biological environment of the case Objectives : 1. comprehensive picture of the case 2. visualise how the disease may have started and progressed 3. how it can be managed and rehabilitated ‘ within the means available to the case ’ 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 2

3. Common Cases MCH Antenatal Post natal Under five case Acute respiratory illness Acute diarrheal disease Malnutrition / Under nutrition CD/NCD Tuberculosis Leprosy Fever DM HT RTI/STI 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 3

4. What is the difference between Community Medicine history taking and Clinical Medicine? Assessment of: Socio economic status – Occupation, Education and Income Environmental conditions – Environmental history Nutritional status – Complete Dietary history Family background – Complete family history Socio cultural factors or determinants - Socio cultural history 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 4

5. PURPOSE 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 5

6. Example Clinical diagnosis Type 2 Diabetes Mellitus With complications (Peripheral Neuropathy ) Social diagnosis working as an auto driver with SES class IV and overcrowding at the house with high BMI consuming normal calories for his age and gender and a chronic alcoholic with poor knowledge on diabetes treatment underwent an indigenous treatment for the management of wound. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 6

7. CLINICO -SOCIAL CASE STUDY Identification data. Clinical history, Family & Environment history, dietary history, General and Systemic examination of the index case. Clinico -social diagnosis. Management suggested (curative, preventive and promotive) 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 7

8. IDENTIFICATION DATA General Information of the Patient ( index case) Name Age Gender Marital status Religion Complete Residential address (door number, street, locality, area) Educational status level - Important to assess the score for SE status Occupation (type of job and nature of job) – (nature of job – sedentary/moderate/heavy) Informant ( paediatric cases) 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 8

9. TYPES OF WORKERS Unskilled work which does not require any education or training E.g : 1.Peon 2.Packer 3.Watchman 4.Cleaner 5.Sweeper 6.coolie 7.domestic servant Semi-skilled Work which need some training to do routine job efficiently E.g : 1. Security guards 2. Waiter 3. library attendant 4.factory labourer Skilled A skilled employee is one who is capable of working efficiently with independent judgment and of discharging his duties with responsibility. E.g : 1. Electrician 2. Mechanic 3. Tailors 4. Nurses 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 9

10. Types of workers Sedentary worker Mostly resting with little or no planned strenuous activity E.g : Bank employees, Software engineers Moderate worker Mostly standing or walking work environment or daily planned strenuous activity E.g : Teacher, Watchman, factory employees or supervisors etc Heavy worker Working environment is strenuous or routine strenuous activity for several hours E.g : Rickshaw pullers, Daily Construction workers 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 10

11. Complaints of the patient Chief presenting complaints 1 or 2 complaints that made the patient to come to the hospital Present it in chronological order H/O presenting illness Elaborate the chief complaints (duration, mode of onset, severity, aggravating and relieving factors) Associated symptoms (related to the system involved) – Cardinal symptoms of the particular system involved 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 11

12. CHIEF COMPLAINTS HISTORY OF PRESENTING ILLNESS Cough with expectoration for the past 20 days Fever for the past 5 days The patient was apparently normal before 20 days The cough started 20 days onwards initially it was dry and then gradually presented with expectoration, mild yellow colored sputum and occasional foul smelling, the cough was more during the night while lying down relieved in sitting posture. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 12

13. cardinal symptoms of a system CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM Chest pain Breathlessness Palpitation Syncope Breathlessness Chest pain Cough with expectoration Hemoptysis Wheeze 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 13

14. PAST HISTORY H/O Tuberculosis Systemic Hypertension Diabetes Mellitus Chronic Medical Illness Previous surgeries Associated illness Duration & Treatment for the illness Complications due to the illness 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 14

15. Personal history Smoking duration, age started smoking, type [cigar/beedi/any other], frequency [number] per day, any withdrawal symptoms Alcoholism duration, age started, type of alcohol, frequency and quantity per drink, any withdrawal symptoms H/O of any drug abuse: name of the drug, frequency of use, any withdrawal symptoms Bowel/bladder habits – Altered / Normal Sleep-wake cycle 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 15

16. Other relevant history Menstrual history (where relevant). Marital history Obstetric history (where relevant). Birth history( antenatal, natal, postnatal). Immunization history and Developmental history (where relevant). Contact history 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 16

17. POSTNATAL HISTORY Child rearing practices Special practices such as oil bath and kajal application Usual time of commencement of breastfeeding Colostrum given or not Prelacteal feed Artificial milk introduced during breastfeeding—yes/no, method of feeding, dilution Usual age at which weaning is started Usual weaning foods Attitude regarding childhood immunization 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 17

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19. Family FAMILY – A group of people living together who are biologically related individuals or related by marriage or related by adoption and eating from a common kitchen. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 19

20. Types of family Nuclear family Married couple and their children while still they are dependants Extended or Three generation Young couples living with their parents and have their own children 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 20

21. Types of family Joint family Consists of a number of married couples and their children living together in the same household; All the men are related by blood and the women are their wives, unmarried girls and widows of the family kinsmen. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 21

22. Problems in the family Problem family - Poor standard of living, financial problems, psychological or personality problems in family members Broken family – Single parent 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 22

23. PEDIGREE CHART Pedigree Analysis Important tool for studying human inherited diseases Used to determine the mode of  inheritance  (dominant, recessive, etc.) of genetic diseases. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 23

24. PEDIGREE CHART Family with generations Easier to visualize relationships with in families, particularly large extended families. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 24

25. Head of the family Criteria for deciding the HOF among the members of the household: 1. The head of the household for census purposes is a person who is reported as the head by the household members. 2. She or he is generally the person who bears the chief responsibility for managing the affairs of the household and takes decision on behalf of the household. The head of the household need not necessarily be the oldest male member or an earning member 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 25

26. FAMILY HISTORY S no Name Relation to head of the family Age Sex Education Occupation Income Health status 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 26

27. Family history S.No Name of the family member Age (years) Relationship to the Head of the family Education Occupation Income H/O Similar illness in the family 1. Raja 35 HOF Graduate General manager 60,000 /month Has Recurrent Respiratory illness 2. Rani 32 Wife Graduate Home maker Nil No 3. Vasu 12 Son 8 th STD _ _ H/O similar illness a month ago 4. Lakshmi 8 Daughter 3 rd STD _ _ H/O Similar illness 15 days ago TOTAL INCOME 1L / Month Percapita = 60,000/4 = 15,000/Head Calculate Per capita income 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 27

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29. SES Classifications Modified BG Prasad’s classification Used for both urban and rural areas. Most commonly used scale to measure the Socio-economic status of families. Devised in 1961 and was later modified by the author himself in 1968 and 1970 It is based on per capita monthly income. Limitation: Only Income is taken into account Miss out on the other factors affecting the social status of the individual. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 29

30. Per Capita Family Income The income from all the sources should be added up. This is divided by the total number of members of the family, regardless of the age of the individual. For example, even a baby born on the same day is to be counted. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 30

31. Modified BG Prasad classification - 2023 Social class Revised for 2023 (income Rs / Month) Class I 8763 and above Class II 4381.5 – 8675.3 Class III 2630 - 4294 Class IV 1314.5 – 2541.27 Class V < 1314.5 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 31

32. Modified kuppuswamy scale Most commonly used scale for determining the SES in urban and peri urban areas Three parameters:- Education Occupation, and Income This scale enables SES assessment of a family rather than an individual The parameters were modified as education and occupation of the HOF and the pooled income of the whole family Head of the family Pooled family income 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 32

33. EDUCATION OF THE HEAD OF THE FAMILY S. No. Education of the Head Score 1 Profession or Honours 7 2 Graduate 6 3 Intermediate or diploma 5 4 High school certificate 4 5 Middle school certificate 3 6 Primary school certificate 2 7 Illiterate 1 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 33

34. TOTAL MONTHLY INCOME OF THE FAMILY S . No Updated monthly family income in Rupees (2023) Score 1 ≥ 146,104 12 2 109,580 – 146,104 11 3 73,054 – 109,579 10 4 68,455 – 73,053 9 5 63,854 – 68,454 8 6 59,252 – 63,853 7 7 54,651 – 59,251 6 8 45,589 – 54,650 5 9 36,527 – 45,588 4 10 21,914 – 36,526 3 11 7,316 – 21,913 2 12 ≤ 7,315 1 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 34

35. OCCUPATION OF THE HEAD OF THE FAMILY S. No. Occupation of the Head Score 1 Legislators, Senior Officials & Managers 10 2 Professionals 9 3 Technicians and Associate Professionals 8 4 Clerks 7 5 Skilled Workers and Shop & Market Sales Workers 6 6 Skilled Agricultural & Fishery Workers 5 7 Craft & Related Trade Workers 4 8 Plant & Machine Operators and Assemblers 3 9 Elementary Occupation 2 10 Unemployed 1 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 35

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37. Socio economic status: (Using modified kuppuswamy classification/BG Prasad classification Modified BG prasad Total income - 60,000 Number of family members – 4 Percapita income = Total income / Number of family members Percapita income = Rs.15,000 This family in this example Belongs to Class 1 Modified kuppuswamy classification Education of the head of the family - Graduate - 6 Occupation of the HOF General manager – 6 ( Semiprofession ) Family– 12 income- Rs. 60,000 6+6+7 =19 =Upper middle 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 37

38. Other SES Classifications Uday Pareekh classification is used for rural areas The following characteristics namely: Caste Occupation of family head Education of family head Level of social participation of family head Landholding, housing, farm power, material possessions and Type of family 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 38

39. Below Poverty line : It is defined as the expenditure required for a daily calorie intake of 2400 per person in rural areas and 2100 in urban areas. The actual cut off in terms of money depends upon the current price index. The current poverty line is 1,059.42 Indian Rupees per month in rural areas and 1,286 Indian rupees per month in urban areas. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 39

40. DIETARY HISTORY 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 40

41. DIETARY HISTORY Dietary history is done to assess the quantities of food items and nutrients consumed by the family or an individual. There are various methods of dietary history 24-hour recall method (questionnaire method) Weighment of raw foods: Weighment of cooked foods: Food frequency questionnaire 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 41

42. DIETARY HISTORY Use 24 hours recall method Ask the patient regarding his diet consumed the day before It should be converted into calories and proteins approximately Compare it with the reference standard. Calorie requirement of sedentary moderate/heavy worker/male/female Comment on the calories (excess/deficit) 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 42

43. 24-HOUR RECALL METHOD It is one of the easiest and most popular methods for conducting a dietary survey. Studies have revealed that if properly conducted, the 24-hour recall method reveals reliable information regarding the food intake amount and quality. The interviewer asks the patient to recall all the foods consumed by the family in the past 24 hours. suggested that the recall should begin from the most recent meal and proceed backward in time. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 43

44. 24-HOUR RECALL METHOD Some measures are suggested to obtain complete and truthful information: • Explain the patient that you need to know only what was actually eaten. • Do not express either approval or disapproval of any food item that is mentioned, either by way of words or by facial expressions Do not appear to be judgmental about any dietary item being “good” or “bad” • Do not ask leading questions that may suggest the him that the family “should” have consumed a certain item and lead her/ him to say, “Yes,  25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 44

45. DIET HISTORY S no time item Kilocalorie/protein 1 morning 4 idlies 1 cup sambar 1 cup coffee 300 110 110 2 afternoon 2 cup rice 1cup sambar 340 110 3 evening 1 cup coffee 2 biscuits 110 40 4 night 1 cup rice 1 cup sambar 170 110 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 45

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47. Group Category/Age Body weight Net energy (kg) Net energy (kg) (kcal/d) Protein (g/d) men Sedentary work Moderate work Heavy work 65 2,110 2,710 3,470 54 women Sedentary work Moderate work Heavy work Pregnant woman Lactation 0-6 m 6-12 months 55 1,660 2,130 2,720 +350 +600 +520 46 77.5 63 59 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 47

48. ENVIRONMENT Urban /rural area Type of house (Pucca/Semi-pucca/Kutcha) Situation/location Set back (present / absent) Floor, roof, walls, windows, number of rooms Ventilation: adequate/inadequate Lighting: adequate/inadequate Separate kitchen: yes/no (method of storage of food materials). Fuel used, exhaust+/- Garbage disposal Separate store room: Storage of raw materials Separate toilet > Own (Separate/shared)/community type Habit of Open air defecation 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 48

49. ENVIRONMENT Overcrowding : (define according to number rooms per person, space availability/sex separation) Solid waste: storage, transport, disposal (frequency of disposal from the house) Liquid waste –underground drainage /street sewage. Water : Source, storage, palatability, color, odor, whether the water is disinfected or not . water used for cooking purpose Peri-domestic sanitation : Fly breeding and mosquito breeding source H/O pet animals : If yes detailed history of the premises of the animals reared. Immunization history of the animals, cleaning of the animals, animal excreta disposal Pest/rodent menace +/- 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 49

50. housing 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 50

51. Amma Canteen Comm. Hall PDS ICDS AREA MAP HOUSE MAP 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 51

52. TYPE OF HOUSE 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 52

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54. SEMIPUKKA 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 54

55. OVERCROWDING .  accepted standard of floor space per person is given in the following Table 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 55

56. Persons per Room Criteria 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 56

57. SEX SEPARATION CRITERIA According to this criterion, overcrowding is considered to be present if two persons, above 9 years of age, of opposite sexes, not husband and wife, must sleep in the same room. ‘Must sleep in the same room’, means that there is no other option but to share the room. Rooms used as bedroom, sitting room, prayer room, dining room, servant’s room - all are considered as living rooms and therefore counted and measured for assessing overcrowding. Kitchen, bathroom, latrine, store, garage etc. are not considered as living rooms. However, a room used in common for living purpose and as kitchen or store is also considered as living room. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 57

58. LIGHT Good lighting is essential for efficient vision If the lighting conditions are not ideal, the visual apparatus is put to strain which may lead to general fatigue and loss of efficiency   if one is able to read news print in all the corners and the center of the room and also in the darkest portion of the room, without help of artificial light during day time the lighting can be considered adequate, provided there is no glare and the light does not directly fall in the eyes. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 58

59. VENTILATION  Every living room should be provided with at least two windows with at least one of these opening directly on to an open space. Doors and windows should be so placed as to allow cross ventilation. Total window area should be 1/5th of the floor area. • The total area of the doors and the windows taken together should be 2/5th of the floor area. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 59

60. Socio cultural history (Pertaining to the case) Knowledge about the disease Attitude towards the disease (Approach towards the disease) Practice System of medicine (Allopathy /AYUSH/Indigenous or Native medicines -Local cultural habits/beliefs/customs Useful in making the community diagnosis 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 60

61. General Examination and Systemic examination 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 61

62. CLINICO-SOCIAL DIAGNOSIS 1) Medical diagnosis : This is the diagnosis of the medical condition in the index case, e.g., Type 2 diabetes mellitus. 2)Social diagnosis : This is an enumeration of adverse social factors in the family. These may have, directly or indirectly, influenced the precipitation of the disease or its appropriate management and rehabilitation. For example, low socioeconomic level, illiteracy, no regular follow-ups, alcoholism, having to bring up four children and not using any contraception. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 62

63. MANAGEMENT WHICH LEVEL OF PREVENTION IS FAILED? Management Investigations Treatment Advise Individual and family 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 63

64. MANAGEMENT Individual level Curative : Medical management Preventive : i.e. Advise to prevent further progression, complications, and disability limitation Practical advice for rectifying deficiencies in the environment so as to prevent other diseases in the family members Promotive : This includes advice for improving general health, e.g., improving the dietary habits, vocational advice to improve SES, health education, information regarding Anganwadi and other facilities in the area. • Family level : what should be done and what can be done for the family in the given circumstances. • Community level : if you feel that any intervention at the community level., e.g., organizing health education camps may reduce social stigma and enable patients to utilize treatment facilities, or see if there is a need for a PHC. 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 64

65. THANK YOU 25-02-2024 INSTITUTE OF COMMUNITY MEDICINE 65