Community Medicine Practical: How to Present This Case

A. Long Case: Comprehensive Demographic Profile and Socioeconomic Assessment

1. Identification data

“The allotted family is the family of Mr/Mrs ___, residing at ___ village/ward, under ___ health centre. The family was visited on ___ date. Information was obtained from ___, who was a reliable informant.”

• Address and locality: rural/urban
• Religion/caste, if relevant to health practices
• Type of family: nuclear, joint, three-generation, broken/reconstituted
• Total family members
• Duration of residence and migration, if any
• Family life-cycle stage

2. Family composition table

• Total family size: ___
• Number of males/females: ___ / ___
• Sex ratio:
  [ \text{Sex ratio} = \frac{\text{Number of females}}{\text{Number of males}} \times 1000 ]
• Number of children below 5 years: ___
• School-going children: ___
• Adolescents: ___
• Eligible couple: ___
• Pregnant/lactating woman: ___
• Elderly persons aged 60 years or more: ___
• Dependency ratio:

“The dependency ratio is ___%. A high dependency ratio indicates a greater economic and caregiving burden on earning family members.”

3. Demographic characteristics

A. Family type and size

• Nuclear/joint/three-generation family
• Small/medium/large family
• Whether family size is appropriate to available income and housing
• Any family discord, widowhood, separation, substance use, disability or social vulnerability

B. Marital and reproductive profile

• Age at marriage
• Age at first pregnancy
• Gravida, para, living children, abortions
• Interpregnancy interval
• Current contraceptive use
• Unmet need for family planning
• ANC, institutional delivery, PNC history
• Menstrual and reproductive complaints, if relevant

“Early marriage, teenage pregnancy, short birth interval, high parity and non-use of contraception may increase maternal, newborn and child health risks.”

C. Education

• Head of family
• Mother/caregiver
• Adolescent girls
• School-going children

“Low female literacy can adversely affect health awareness, child feeding, sanitation practices, utilization of maternal and child health services, and contraceptive acceptance.”

D. Occupation

• Occupation of head of family
• Occupation of other earning members
• Nature of employment: regular, contractual, seasonal, unemployed
• Occupational hazards: dust, chemicals, injuries, animal exposure, prolonged posture, stress etc.

E. Income and expenditure

• Total monthly family income from all sources
• Per-capita monthly income:

• Major expenditure: food, rent, education, health care, alcohol/tobacco, debt
• Savings, loans, financial insecurity and insurance coverage

4. Socioeconomic status assessment

Choose the appropriate scale

If the family is urban

1. Education of head of family
2. Occupation of head of family
3. Total monthly family income

Format for presentation

“According to the updated Modified Kuppuswamy classification, the family belongs to socioeconomic class ___.”

If the family is rural

“The family has a per-capita monthly income of ₹___. According to the current updated Modified BG Prasad classification, it belongs to Class ___.”

5. Housing and environmental profile

A. House

• Kutcha, semi-pucca or pucca
• Owned/rented
• Number of rooms
• Separate kitchen: yes/no
• Flooring, roof, walls
• Adequacy of lighting and ventilation
• Presence of smoke in kitchen
• Electricity

B. Overcrowding

C. Water

• Source: piped water, hand pump, well, tanker etc.
• Availability: adequate/inadequate
• Storage practice: covered/uncovered
• Treatment: boiling, filtration, chlorination, none
• Distance from source, if relevant

D. Sanitation and waste disposal

• Type of toilet: sanitary latrine/open defecation
• Wastewater disposal: closed/open drain
• Solid waste disposal: collection, composting, open dumping, burning
• Mosquito breeding sites
• Presence of flies, rodents, stray animals

E. Domestic environment

• Domestic animals and their location
• Cooking fuel: LPG, biomass, kerosene etc.
• Tobacco smoke exposure
• Alcohol/substance use
• Food storage and hand-washing practices

6. Health profile of family members

• Fever, cough, tuberculosis symptoms
• Hypertension and diabetes
• Obesity/underweight
• Anaemia
• Tobacco, alcohol and other substance use
• Mental health concerns
• Visual/hearing/dental problems
• Disability
• Elderly care needs
• Adolescent health issues
• Menstrual hygiene and reproductive health
• Communicable disease history
• Immunization status of children
• ANC and immunization status of pregnant woman, if present

7. Nutritional assessment

• Diet pattern: vegetarian/mixed diet
• Meal frequency
• Dietary diversity
• Intake of green leafy vegetables, pulses, milk, fruits and animal-source foods
• Infant and young child feeding practices
• Under-five growth chart and immunization card
• Height, weight, BMI for adults, if available

• Underweight
• Overweight/obesity
• Anaemia risk
• Protein-energy malnutrition in children
• Inadequate complementary feeding
• Excess salt, sugar or oil intake

8. Comment on impact of demographic and SES findings on health

Suggested format

“The family belongs to ___ socioeconomic class. The family has ___ members, with a dependency ratio of ___%. They live in a ___ house with/without overcrowding. Water supply is ___ and sanitation is ___. The family has the following vulnerable groups: ___.”

9. Advice and family health plan

Priority 1: Immediate problems

• Refer any symptomatic patient, severe anaemia, uncontrolled hypertension/diabetes, suspected TB, pregnancy danger sign or malnourished child.
• Ensure treatment adherence and follow-up.

Priority 2: Maternal and child health

• Complete ANC, IFA, calcium, tetanus-containing vaccine and institutional delivery plan.
• Ensure full immunization of children.
• Growth monitoring, exclusive breastfeeding for 6 months and appropriate complementary feeding after 6 months.
• Counsel eligible couple on spacing or limiting methods as appropriate.

Priority 3: Nutrition

• Low-cost balanced diet using locally available cereals, pulses, green leafy vegetables, seasonal fruits, milk/eggs where acceptable.
• IFA supplementation when indicated.
• Reduce excess salt, sugar, fried foods and ultra-processed foods.

Priority 4: Sanitation and environment

• Safe storage and treatment of drinking water.
• Use sanitary toilet.
• Covered waste bins and proper waste disposal.
• Remove stagnant water weekly.
• Improve ventilation and kitchen smoke outlet.
• Encourage LPG/clean fuel use where feasible.
• Reduce overcrowding where possible.

Priority 5: NCD and lifestyle prevention

• Tobacco and alcohol cessation counselling.
• Regular BP, blood glucose and BMI screening for adults.
• Daily physical activity and healthy diet.

Priority 6: Linkage to services

• ASHA/ANM
• Anganwadi centre
• Health and Wellness Centre/PHC
• Government immunization services
• TB and NCD screening services
• Family-planning services
• Appropriate social welfare or insurance schemes, if eligible

B. Short Case: Index Case

1. Identification and summary

“My index case is ___, a ___-year-old ___, resident of ___, who has ___ for ___ duration. The patient was diagnosed with ___ and is currently receiving ___ treatment.”

• Age, sex, occupation
• Address/locality
• Main complaint/diagnosis
• Duration
• Relevant treatment and adherence
• Important examination findings/investigation reports
• Relevant family and contact history

2. Clinico-social diagnosis

Template

“This is a case of ___ in a ___-year-old ___, currently on ___, associated with/complicated by ___. The illness is influenced by ___ socioeconomic status, ___ housing/overcrowding, ___ nutritional status, ___ occupational exposure, ___ behavioural risk factors and ___ family support/treatment adherence.”

Example structure

“This is a case of hypertension in a 52-year-old male, with irregular treatment adherence, overweight, high dietary salt intake and tobacco use, belonging to a lower-middle socioeconomic family. Poor health awareness and irregular follow-up are contributing social factors.”

“This is a case of pulmonary tuberculosis in a ___-year-old person, with possible exposure risks including overcrowding, poor ventilation, low socioeconomic status and nutritional vulnerability. Contact screening and treatment adherence need assessment.”

3. Management

A. Clinical management

• Confirm diagnosis and severity
• Review investigations
• Ensure correct treatment
• Assess adherence, adverse effects and complications
• Refer urgently if danger signs are present

B. Preventive management

• Specific prevention according to illness
• Immunization where applicable
• Contact screening, if infectious disease
• Screening for co-morbidities and risk factors
• Nutrition and lifestyle counselling

C. Social and environmental management

• Improve housing, ventilation, water, sanitation and waste disposal as relevant
• Reduce occupational exposure
• Address financial barriers and access to government services
• Family counselling and caregiver involvement

D. Follow-up

• Date and place of follow-up
• Who will monitor: family, ASHA, ANM, PHC
• Treatment adherence check
• Repeat BP/sugar/weight/sputum test or other disease-specific parameter

Suggested Final Conclusion for the Long Case

“In conclusion, this is a ___ family in the ___ stage of family life cycle, belonging to ___ socioeconomic class according to ___ scale. Important health determinants identified are ___, ___ and ___. The priority health needs are ___, ___ and ___. A family-centred plan including treatment, preventive care, nutrition, environmental sanitation, health education and linkage with primary health-care services has been advised.”

Key viva points to remember

1. Urban family: Modified Kuppuswamy Scale.
2. Rural family: Modified BG Prasad Scale.
3. Always mention the updated income scale/year used.
4. Calculate and interpret per-capita income, dependency ratio, and persons per room where possible.
5. A clinico-social diagnosis must include both the disease and its social determinants.
6. Advice should be individualized to the family’s actual findings.

A woman who is fecund and sexually active, does not want a child now or does not want any more children, but is not using any contraceptive method.

1. Unmet need for spacing
   She wants to delay the next pregnancy for at least 2 years, but is not using contraception.
2. Unmet need for limiting
   She does not want any more children, but is not using contraception.

Example

1. Modified Kuppuswamy Scale

Use

• Mainly used for urban families
• Assesses socioeconomic status using three parameters:
  1. Education of the head of family
  2. Occupation of the head of family
  3. Total monthly family income

A. Education of head of family

B. Occupation of head of family

C. Monthly total family income

D. Final classification

How to say it in viva

“The head of family is a high-school pass worker, employed as a skilled worker, and the total monthly family income is ₹___. The respective scores are ___, ___ and ___. The total score is ___. Therefore, according to the updated Modified Kuppuswamy scale, the family belongs to Class ___ socioeconomic status.”

2. Modified B. G. Prasad Scale

Use

• Can be used for both rural and urban families
• Based only on per-capita monthly income
• It does not consider education or occupation.

Classification

How to say it in viva

“The total monthly family income is ₹___ and the total family size is . Therefore, the per-capita monthly income is ₹. According to the updated Modified B. G. Prasad classification, the family belongs to socioeconomic Class ___.”

Kuppuswamy vs B. G. Prasad: Important difference

Exam one-liner

“For an urban family, I will use Modified Kuppuswamy scale. For a rural family, Modified B. G. Prasad scale is commonly preferred because it is based on per-capita income and is applicable in both rural and urban settings.”

Modified Kuppuswamy Scale: Family Monthly Income Scores

1. Geriatric dependency ratio

2. Ageing index

How to present an elderly index case

1. Identification

“My index case is Mr/Mrs ___, a ___-year-old male/female, residing at ___, who is currently living with ___ family members.”

• Age, sex, marital status
• Education and previous/current occupation
• Family type and main caregiver
• Financial dependence or pension
• Living arrangement: with spouse/children/alone

2. Chief health problems

• Hypertension, diabetes, heart disease, stroke
• Joint pain/osteoarthritis, backache
• Visual or hearing difficulty
• Dental problems
• Breathlessness/COPD
• Urinary symptoms/incontinence
• Falls or fractures
• Sleep problems
• Memory loss, depression, loneliness
• Difficulty in walking or daily activities
• Multiple medicines and treatment adherence

3. Functional assessment

• Cooking
• Shopping
• Handling money
• Taking medicines
• Using phone/transport

4. Social assessment

• Is the elderly person financially dependent?
• Is there family support and regular caregiving?
• Any neglect, abuse or isolation?
• Is the home safe from falls: poor lighting, stairs, loose rugs, slippery bathroom?
• Does the person receive old-age pension or health insurance support?

5. Nutritional assessment

• Appetite and number of meals
• Difficulty chewing/swallowing
• Recent weight loss
• Adequacy of protein, fruits, vegetables and milk
• Anaemia risk

6. Clinico-social diagnosis

“This is a ___-year-old elderly ___ with ___ [medical illness], associated with ___ [functional limitation], with/without financial dependence, and living in ___ family support conditions. Contributing factors include ___ [poor adherence, inadequate diet, fall risk, lack of caregiver support, poor access to health services, social isolation, etc.].”

Example

“This is a 72-year-old widowed female with hypertension and osteoarthritis of both knees, with difficulty in walking and dependence for outdoor activities. She is financially dependent on her son and has limited access to regular follow-up. Her clinico-social problems include chronic disease, reduced mobility, fall risk, inadequate physical activity and partial financial dependence.”

7. Management and advice

• Ensure regular BP, blood glucose and other disease-specific monitoring.
• Check medicine adherence and avoid unnecessary multiple medications.
• Refer for eye, hearing, dental, physiotherapy or specialist assessment as needed.
• Encourage safe daily physical activity, walking and balance exercises as tolerated.
• Give advice on adequate protein-rich diet, calcium and vitamin D sources.
• Fall prevention: proper footwear, good lighting, handrails, non-slip bathroom, remove loose mats.
• Screen for depression, dementia, loneliness, elder abuse and caregiver strain.
• Link to PHC/Health and Wellness Centre and NPHCE services.
• Explain that PHCs may provide geriatric assessment, chronic disease management, medicines and referral services under NPHCE. Park’s Textbook of Preventive and Social Medicine, National Programme for Health Care of the Elderly.

Advice given to a geriatric female

“She was advised to take her prescribed medicines regularly and attend the PHC/geriatric clinic for periodic blood pressure, blood glucose and general health assessment. She was counselled regarding a balanced, protein-rich diet with adequate milk/curd, pulses, green leafy vegetables, fruits and sufficient water intake. She was advised regular light physical activity, such as walking and balance exercises, according to tolerance.

Fall-prevention advice was given: use proper footwear, ensure adequate lighting, avoid wet/slippery floors and loose mats, and use support while walking if required. She was advised regular eye, dental and hearing check-ups. Screening for anaemia, diabetes, hypertension, vision problems and depression was advised. Family members were counselled to provide emotional support, help with medicines and hospital visits, and watch for symptoms such as falls, confusion, persistent sadness, loss of appetite or worsening breathlessness.”

Add if she has chronic disease

• Hypertension: reduce salt, avoid missing medicines, regular BP monitoring.
• Diabetes: avoid excess sugar/refined carbohydrates, foot care, regular blood glucose follow-up.
• Osteoarthritis/joint pain: physiotherapy, weight control, avoid squatting and unnecessary stairs.
• Osteoporosis risk: calcium and vitamin D-rich diet, safe sunlight exposure, fall prevention.
• Widow/living alone: assess loneliness, financial dependence, pension and family support.

“She was linked with the Health and Wellness Centre/PHC under NPHCE for geriatric assessment, chronic disease management, medicines and referral if needed.”

1. Cradle hold
   Baby lies across the mother’s abdomen. Baby’s head rests in the elbow bend of the arm on the same side as the feeding breast.
2. Cross-cradle hold
   Mother supports baby’s head and neck with the opposite hand. Useful for newborns and for helping the baby latch properly.
3. Football or rugby hold
   Baby is tucked at the mother’s side under her arm, with feet pointing backwards. Useful after caesarean delivery, for twins, large breasts, sore nipples, or engorgement.
4. Side-lying position
   Mother and baby lie facing each other on their sides. Useful after caesarean delivery or when the mother needs rest. Ensure the baby is returned to a safe separate sleep surface after feeding.
5. Laid-back or reclining position
   Mother reclines comfortably and baby lies prone, chest-to-chest on the mother. Helpful when the baby has difficulty latching.

Correct positioning of the baby: “Four points”

• Baby’s head and body are in a straight line
• Baby’s face is facing the breast, nose opposite the nipple
• Baby’s body is close to the mother’s body
• Mother supports the baby’s whole body, not only head and neck

Signs of good attachment

• Mouth wide open
• Chin touching the breast
• Lower lip turned outward
• More areola visible above the baby’s upper lip than below
• Slow, deep suckling with audible swallowing