Social clinical case antenatal

Community Medicine

1. Social Clinical Case Ante natal Dr. Ghulam Mustafa Kataria Department of Community Medicine, SKIMS, Srinagar

2. Identification data of the index case Name. Age. Marital status. Religion. Education. Occupation. Address.

3. Family details Type of family. Composition of the family. > Total number of family members. > Decide who is the 'Head of the family' (HOF). Description of the family members. Socioeconomic data of the family Per capita income per month (of the family): Rs ______________, above/below poverty line Socioeconomic status (SES) of the family: __________________ class (____________ scale)

4. Chief Complaint( how many days, aggravating & relieving factors). Amenorrhoea Fever. Persisting vomiting. Abnormal vaginal discharge/ Bleeding. Palpitation, easy fatigability Breathlessness at rest or on mild exertion. Generalized swelling on body. Severe head ache, blurring of vision. Burning in passing urine. Decreased or absent fetal movement

5. P resent pregnancy: Spontaneous conceived/wanted pregnancy. Confirmed by UPT: When , Where and by whom? Registration: When- Where History of Present Pregnancy : Visit No. Trimester. Period of Gestation. Wt. Rx. Given Investigation done. Fundal height.

6. Ist Trimester: Folate Supplemets TT Drug intake, rashes, radiation, trauma. Vomiting. Bleeding P/V Wt.gain . Invstigation .

7. 2 nd Trimester: Quickening, foetal movement Any danger sign. Investigation. Menstrual History: LMP. EDD . Menarche. Regularity- once in how many days, for –days Clot, Pain.

8. Marital History: Age of marriage (Husband /Wife). Time gap b/w marriage and pregnancy. Contraceptive method if used . Consanguious /Non Consanguious .

9. Past Obstetric History : GPLADS Age at First Pregnancy: History of abortion/Still birth /MTP Past History: History of GDM/GHTN, any other complication.

10. History of any current systemic illness. History of drug allergies , Drug intake. Family history of chronic disease/ congenital malformation.

11. History of family planning : Awareness / Method used earlier Personal History : Appetite, Sleep, Bowl, Bladder Hygiene: Hand washing practice. Bathing/ Brushing Dietary detail : Energy requirement. Energy consumed. Calorie deficit. Protein: Requirement/ consumed/deficit.

12. Examination General physical examination : Orientation with Time, Place, Person. Pulse. BP. RR. Temperature. Pallor/Icterus/Cyanosis. Swelling/Clubbing etc. Anthropometry. Breast Examination.

13. Systemic examination : CVS. RESP. CNS. Abdominal.

14. FAMILY HEALTH STUDY General Health problems in other family members Immunization status of other family members. Sanitary assessment of the house and environment. Kitchen. Water supply. Refuse disposal.

15. 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. > Any other custom. > Attitude regarding childhood immunization.

16. Health practices > Which system of medicine is followed? > Where do they avail the services in time of illness? > Knowledge, attitude, and practices (KAP) regarding common illness > Recreational facilities.

17. CLINICO-SOCIAL DIAGNOSIS Medical diagnosis: This is the diagnosis of the medical condition in the index case. Social diagnosis: This is an enumeration of adverse social factors in the family. For example, low socioeconomic level, illiteracy. Strengths: This involves an analysis of the support system for the case. For example, a nearby health facility holding weekly diabetes clinic and patient's positive attitude toward following medical advice.

18. MANAGEMENT SUGGESTED Individual level: Curative, Preventive,Promotive . Family level Community level