Format for Clinico-Social Case Taking in Community Medicine

The objective of clinico-social case (CSC) taking is to examine the "index case” in the milieu of
• His/her family and
• Environment

The aim is to make a comprehensive diagnosis and to suggest a comprehensive treatment.
Therefore in addition to clinical history and examination of the index case, information should also be collected about important health issues of other family members and also the living environment of the case.

There are several formats in use in various institutes.
As long as complete information is gathered, none of the formats can be regarded as superior to the other. One such format is suggested here for collection and presentation of information regarding the allotted CSC.

The case information can be collected under the following broad headings:
1. Identification and family data
2. Clinical history, general, and systemic examination of the index case
3. Family health and Housing Environment
4. Clinico-social diagnosis
5. Effect of the illness on the family
6. Management suggested (curative, preventive, and promotive)

Identification and Family Information
• Identification data of the index case
• Name
• Age
• Sex
• Marital status
• Religion
• Address

Family details
• Type of family: Nuclear/joint/three generation
• Composition of the family
> Total number of family members
> Decide who is the 'Head of the family' (HOF)
• Description of the family members indicating the allotted case's position as per the following table:

Recording Family Bio Data

• 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)

MEDICAL HISTORY AND EXAMINATION of the index case
History
• Presenting complaints
• History of present illness till date, including treatment taken
• Past history
• Family history
• Dietary history
• Menstrual history (where relevant)
• Obstetric history (where relevant)
• Developmental history (where relevant)
• Immunization history
• Personal history

Examination
• General physical examination—Anthropometry, pulse, RR, BP, etc.
• Systemic examination
• Medical provisional diagnosis
• Attitude of the patient toward his/her illness

FAMILY HEALTH STUDY
General
• Health problems in other family members
• Immunization status of other family members

Sanitary assessment of the house and environment
• House
> Type of house—Pucca/kutcha/etc.
> Overcrowding—Present/absent
> Ventilation—Adequate/inadequate
> Lighting
■ Natural light—Adequate/inadequate
■ Artificial light—Adequate/inadequate
> Mosquito Breeding
> Potential Mosquito breeding areas—Present/ absent
How does mosquito breeding look like? See here: https://youtu.be/jOmA8bbP1RU
> Actual Mosquito breeding – Present/Absent
> Fly breeding areas—Present/absent
> Cattle distance from the living room
> Rodents in the house—Present/absent
> Pets in the house—Present/absent

• Kitchen
> Separate/open/living room
> Floor type
> Clean/dirty
> Storage of cooked food
> Storage of uncooked food
> Fuel used
> Smoke outlet—Present/absent
> Drainage—Open/closed

• Water supply
> Intermittent/continuous
> Source of drinking water
> Source of water for other purposes
> Storage of drinking water
> Method of drawing out water for drinking from the container
> Check for evidence of mosquito breeding in the stored water. (You can see mosquito larvae which move to the bottom in response to any disturbance): see here: https://youtu.be/jOmA8bbP1RU

• Refuse disposal
> How stored inside house
> How disposed out of the house
> Frequency of disposal

• Latrine
> Own/shared/community type
> Type of latrine

• Social environment
> Any cause of psychological stress.
> How does the family manage situations of crisis?
> Is the family generally accepted by the community?
> Personal hygiene of the family members.

• Customs and health practices
> System of marriage
> Usual age at marriage of boys
> Usual age at marriage of girls
> Average expenditure on marriage
> Dowry prevalent or not
> Any other significant custom regarding marriage

• Maternal and child health practices
> Pregnancy—Special diet, physical activity, antenatal care taken routinely
or not, any other significant custom during pregnancy
> Lactation—Special diet, physical activity, any other significant custom during lactation
> Is isolation observed during puerperium?
> Usual period of lying-in
> Any other significant custom

• 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

• 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.

Knowledge, Attitude and Practice (KAP) regarding contraception
 Knowledge that births can be planned.
 If yes, what are the methods?
 Do they know where to avail the services for contraception?
 Are they using contraception?
 Which method?
 If no, why not?
Identify all the eligible couples in the household and assess their contraceptive use.

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.
Enumerate the inadequacies found in the family health study, e.g., overcrowding, illiteracy in any family member, children not fully immunized, not studying in age appropriate class, school dropout, poor ventilation, and not using iodized salt.
3)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.
The history taking and examination in a CSC may be considered adequate if after analyzing the information, the following questions can be answered satisfactorily:
• What were the factors responsible for this stage of the illness?
• Which levels of prevention have failed and how this could have been prevented?

MANAGEMENT SUGGESTED
• Individual level
Curative: Medical management of the index case and
Preventive: i.e. Advise to prevent further progression, complications, and disability limitation
> Practical advice for rectifying deficiencies observed 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: Write down what should be done and what can be done for the family in the given circumstances.
• Community level: Write down if you feel that any intervention at the community level may help in preventing such cases or improve the management, 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.

References
1. Poornima Tiwari, Shashank Tiwari. Chapter 17: Format for Clinico-Social Case Taking. Mastering Practicals: Community Medicine. Lippincott Williams & Wilkins; Gurugram, Haryana, India

2. Bhalwar R, Parashar SSL. Family health history & individual medico – social history – taking. In: Vaidya R, Tilak R, Gupta R, Kunte R, editors. Text Book of Public Health and Community Medicine. Pune: Dept. Community Medicine, AFMC, in collaboration with WHO, India office, Delhi; 2009:613–8.
3.Jerome G. Mosquito borne diseases. In: Infectious Diseases and Arthropods, 2nd ed. Totowa, NJ: Humana Press; 2008.

For more detailed explanation listen to the lectures. Both Hindi and English versions are available:
Hindi lecture on CSC taking: https://www.youtube.com/watch?v=9gvuXrIJ_gY&t=10s
English lecture on CSC taking: https://www.youtube.com/watch?v=rKxXIyJuBz8&t=24s
Lecture on the definitions and explanations of terms used in Family Health Study: http://www.ihatepsm.com/resource/terms-used-family-health-study-definiti...
Hindi lecture on the definitions and explanations of terms used in Family Health Study: http://www.ihatepsm.com/resource/terms-used-family-health-study-definiti...

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Format for Clinico-Social Case Taking in Community Medicine