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Case History Presentation of a Child in PSM (Preventive and Social Medicine)

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1. BIODATA (Demographic Information)

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2. CHIEF COMPLAINTS

• List presenting complaints in the child's/informant's own words
• Arrange in chronological order with duration
• Example: Fever x 5 days, cough x 3 days, refusal of feeds x 1 day

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3. HISTORY OF PRESENT ILLNESS (HPI)

• Onset: sudden / gradual
• Duration and progression
• Nature and severity of each complaint
• Associated symptoms (relevant positives and negatives)
• Any precipitating / relieving factors
• Treatment already taken (home remedies, OTC drugs, previous consultation)

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4. BIRTH HISTORY

• Antenatal History:
  • Number of antenatal check-ups received (standard: minimum 4 ANC visits recommended)
  • IFA (Iron-Folic Acid) supplementation received - yes/no, how many tablets
  • TT (Tetanus Toxoid) doses received
  • Any complications during pregnancy (hypertension, anaemia, infections)
  • Maternal nutrition status during pregnancy
  • PPTCT (Prevention of Parent-to-Child Transmission of HIV) status if relevant
• Natal History:
  • Place of delivery: Home / PHC / Hospital (reflects institutional delivery rates)
  • Type of delivery: Normal / Caesarean / Assisted
  • Conducted by: TBA / ANM / Doctor
  • Gestational age at birth: Term / Preterm / Post-term
  • Birth weight: (LBW = <2500g; Normal = ≥2500g)
  • Any perinatal complications: birth asphyxia, NICU admission
• Postnatal History:
  • Early newborn care: cord care, kangaroo mother care, warmth
  • Time of first cry, Apgar score if available
  • Any neonatal jaundice, infections, convulsions

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5. FEEDING HISTORY

• Breastfeeding:
  • Initiation of breastfeeding: within 1 hour / delayed (colostrum given or discarded)
  • Exclusive breastfeeding: yes / no, duration (standard = 6 months)
  • Frequency and adequacy of feeds
• Complementary Feeding:
  • Age at introduction (standard: at 6 completed months)
  • Type and variety of complementary foods
  • Adequacy in terms of frequency, amount, and texture (as per IYCF guidelines)
• Current Diet:
  • Type: vegetarian / mixed / predominantly cereal-based
  • Frequency of meals/day
  • Inclusion of fruits, vegetables, protein sources (eggs, pulses, meat)
  • Use of fortified foods / micronutrient supplements
• Special Notes: History of food insecurity, fasting practices, weaning problems

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6. IMMUNIZATION HISTORY

• Status: Complete / Incomplete / Not immunized
• Document each vaccine received against the National Immunization Schedule:

• BCG scar present: Yes / No
• Any AEFI (Adverse Events Following Immunization)
• Any additional (optional) vaccines received (rotavirus, varicella, hepatitis A, etc.)

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7. DEVELOPMENTAL HISTORY

• Any developmental delay, regression, or disability noted
• Early childhood development stimulation received (anganwadi, home)

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8. PAST HISTORY

• Previous illnesses: episodes of ARI, diarrhoea, tuberculosis, malaria, measles, polio
• Hospitalizations and surgical procedures
• Any known allergies (drug/food)
• History of seizures or febrile fits

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9. FAMILY HISTORY

• Similar illness in family members
• Hereditary or genetic disorders
• Tuberculosis, diabetes, hypertension in parents/grandparents
• Deaths of siblings (especially under 5) - causes, number

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10. SOCIOECONOMIC HISTORY

• Modified Kuppuswamy Scale (Urban) / BG Prasad Scale (Rural):
  • Father's education
  • Father's occupation
  • Monthly family income
  • Final socioeconomic class: Upper / Upper-middle / Middle / Lower-middle / Lower
• Family type: Nuclear / Joint / Extended
• Family size and composition: Total members, number of children under 5
• Housing:
  • Type: Pucca / Semi-pucca / Kutcha
  • Number of rooms, per capita space
  • Ventilation, lighting
• Overcrowding: Persons per room (>3 = overcrowded)

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11. ENVIRONMENTAL HISTORY

• Water supply: Source (tap, well, hand pump, tanker), storage, treatment
• Sanitation: Type of toilet (flush / pit / open defecation)
• Waste disposal: Method, proximity to residence
• Indoor air pollution: Use of biomass fuel (firewood, dung cakes) for cooking, cooking location, exposure to tobacco smoke
• Vectors in vicinity: Mosquitoes, flies, rodents
• Proximity to health services: Distance to nearest PHC/Sub-centre

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12. MATERNAL HEALTH HISTORY

• Mother's age, parity, birth spacing
• Mother's nutritional status and BMI
• Mother's education and literacy (key determinant of child health)
• History of anaemia in mother (Hb levels)
• Mother's immunization status (TT, Hep B)
• Mother's awareness: ORS use, danger signs, breastfeeding practices

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13. GENERAL EXAMINATION

• General appearance: conscious, active, playful / lethargic / ill-looking
• Vital signs:
  • Temperature (normal: 36.5-37.5°C)
  • Pulse rate (age-appropriate range)
  • Respiratory rate (fast breathing: ≥60/min in <2 months; ≥50 in 2-12 months; ≥40 in 1-5 years)
  • Blood pressure (if indicated, age-appropriate)
  • Capillary refill time, SpO2
• PICCLE:
  • Pallor (conjunctival, palmar) - classify anaemia
  • Icterus
  • Clubbing
  • Cyanosis (central / peripheral)
  • Lymphadenopathy
  • Edema (pedal, facial, generalized - pitting/non-pitting)
• Skin: Rashes, pigmentation, skin fold thickness

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14. ANTHROPOMETRIC ASSESSMENT (AUXOLOGY)

• Plot on WHO/IAP growth charts: Weight-for-Age, Height-for-Age, Weight-for-Height
• Classify nutritional status:
  • Gomez classification (Weight-for-age): Grade I (<90%), Grade II (<75%), Grade III (<60%)
  • Waterlow classification (stunting + wasting)
  • WHO Z-scores: WAZ, HAZ, WHZ (<-2 SD = moderate; <-3 SD = severe)
  • MUAC: <11.5 cm = SAM; 11.5-12.5 cm = MAM (in 6-59 months)
• Signs of specific deficiencies:
  • Bitot's spots, night blindness (Vit A)
  • Beading of ribs, Harrison's sulcus (Vit D / Rickets)
  • Angular stomatitis, glossitis (B-complex)
  • Oedema (Kwashiorkor), muscle wasting (Marasmus)

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15. SYSTEMIC EXAMINATION

• Respiratory system: respiratory rate, chest indrawing (severe pneumonia), stridor, auscultation
• Cardiovascular system: heart sounds, murmurs
• Abdomen: liver, spleen size, tenderness, hernias
• Central nervous system: tone, reflexes, consciousness (Modified GCS or AVPU), meningeal signs
• ENT: Throat, ears (discharge, perforation), nasal discharge
• Eyes: Conjunctiva (pallor, icterus, Bitot's spots), pupillary reflexes
• Skin and hair: edema, rashes, hair changes (flag sign, depigmentation)
• Genitalia: if relevant

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16. RELEVANT PUBLIC HEALTH / COMMUNITY ASPECTS

• IMCI (Integrated Management of Childhood Illness): Classify illness as per IMCI algorithm - Very Severe Disease / Severe / Moderate / Mild
• Five key family practices (IMCI):
  1. Exclusive breastfeeding for 6 months
  2. Timely complementary feeding
  3. Timely immunization
  4. Use of ORS and zinc in diarrhoea
  5. Care seeking for danger signs
• Government schemes utilised:
  • ICDS (Integrated Child Development Services) / Anganwadi attendance
  • Poshan Abhiyaan, PMMVY (Pradhan Mantri Matru Vandana Yojana)
  • RBSK (Rashtriya Bal Swasthya Karyakram) - health screening
  • NRC (Nutrition Rehabilitation Centre) referral if SAM
  • JSY/JSSK for birth
• Village-level health infrastructure: ASHA, AWW, ANM contact and role

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17. PROVISIONAL DIAGNOSIS

• Clinical diagnosis based on history and examination
• Nutritional diagnosis separately stated (e.g., Severe Acute Malnutrition with bilateral pitting oedema = Kwashiorkor)
• Co-morbidities listed

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18. INVESTIGATIONS SUGGESTED

• CBC (haemoglobin, WBC, platelets)
• Blood smear for malaria (if endemic area)
• Urine routine and microscopy
• Stool routine and microscopy
• Serum albumin, total protein (if malnutrition)
• Mantoux test / X-ray chest (if TB suspected)
• Anthropometric measurements already done (as above)

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19. TREATMENT / MANAGEMENT PLAN

• Specific treatment for the diagnosed condition
• ORS and Zinc for diarrhoea (zinc 20 mg/day x 14 days in children >6 months; 10 mg/day in <6 months)
• Antibiotic as per IMCI guidelines for pneumonia

• F-75 / F-100 feeds for SAM as per WHO protocol (if applicable)
• Micronutrient supplementation: Vitamin A megadose, Iron-Folic Acid, Zinc

• Complete pending immunizations (catch-up schedule)
• Vitamin A prophylaxis (100,000 IU at 9 months; 200,000 IU 6-monthly from 18 months)
• Iron supplementation: weekly IFA for children 6 months to 5 years (National programme)

• Counselling mother on: breastfeeding, complementary feeding, hygiene, danger signs
• WASH (Water, Sanitation, Hygiene) counselling
• Safe food storage and preparation
• Referral to Anganwadi / ICDS for supplementary nutrition

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20. PROGNOSIS

• Short-term and long-term prognosis
• Risk factors for poor outcome (SAM, recurrent infections, social deprivation)

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KEY DIFFERENCES: PSM Case History vs. Clinical (Pediatric) Case History

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CASE HISTORY PRESENTATION

Child with Pneumonia - PSM Format

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1. BIODATA

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2. CHIEF COMPLAINTS

1. Fever - 5 days
2. Cough - 4 days
3. Fast breathing / difficulty breathing - 2 days
4. Refusal of feeds - 1 day

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3. HISTORY OF PRESENT ILLNESS

• No history of convulsions
• No history of measles or contact with a TB patient
• No history of stridor
• No vomiting or diarrhea
• Child previously had 2 episodes of cough and cold in the past 6 months (treated at local PHC with symptomatic medications)
• No prior antibiotic use in the current illness

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4. BIRTH HISTORY

Antenatal History

• Mother registered at Sub-centre at 3 months of pregnancy
• 3 ANC visits completed (below recommended 4 visits)
• TT doses: 2 doses received
• IFA tablets: received for 2 months (compliance irregular)
• No history of gestational hypertension, gestational diabetes, or antepartum haemorrhage
• Mother had pallor during pregnancy (Hb not checked)

Natal History

• Home delivery conducted by local Dai (TBA)
• Full-term, normal vaginal delivery
• Birth weight: Not recorded (no documentation; estimated by mother as "normal")
• No history of birth asphyxia, no NICU admission

Postnatal History

• Baby cried immediately after birth
• No history of neonatal jaundice, neonatal convulsions, or neonatal sepsis
• Cord tied with unclean thread (home delivery) - no complications noted

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5. FEEDING HISTORY

• 2 meals per day (chapati + dal)
• Vegetables: occasionally
• Eggs/meat: rarely (economic constraints)
• No fruits
• No fortified foods
• Estimated dietary intake is inadequate in proteins and micronutrients

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6. IMMUNIZATION HISTORY

• BCG scar: Present (right deltoid)
• Hib vaccine: Not received
• No AEFI reported
• Child not fully immunized - missed Hep B-3, DPT-3, DPT booster, MR-2
• (Incomplete immunization - susceptibility to H. influenzae pneumonia, pertussis)

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7. DEVELOPMENTAL HISTORY

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8. PAST HISTORY

• 2 episodes of Acute Respiratory Infection (ARI) in the past 6 months (treated with symptomatic drugs at PHC)
• 1 episode of diarrhea at age 2 years (ORS given; no hospitalization)
• No history of measles, chickenpox, tuberculosis, or malaria
• No known drug allergies
• No history of seizures or febrile fits
• No surgeries or previous hospitalisations

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9. FAMILY HISTORY

• No death of under-5 siblings in the family
• Father's indoor smoking (bidi) is a significant risk factor for recurrent respiratory infections in Akash

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10. SOCIOECONOMIC HISTORY

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11. ENVIRONMENTAL HISTORY

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12. MATERNAL HEALTH HISTORY

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13. GENERAL EXAMINATION

• General appearance: Child is conscious, irritable, febrile, in mild-moderate respiratory distress; lying in mother's lap
• Cry: Weak but audible
• Activity: Reduced; not playing

• Pallor: Present (conjunctival pallor - mild)
• Icterus: Absent
• Clubbing: Absent
• Cyanosis: Absent (SpO2 94% - borderline)
• Lymphadenopathy: Small bilateral cervical lymph nodes palpable (~0.5 cm), non-tender
• Edema: Absent

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14. ANTHROPOMETRIC ASSESSMENT

• No Bitot's spots; no night blindness reported
• No features of Vitamin D deficiency
• Pallor suggesting iron deficiency anaemia

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15. SYSTEMIC EXAMINATION

Respiratory System

• Inspection: Chest indrawing present (lower chest wall draws IN with each breath), bilateral; tachypnoea (RR 46/min)
• Palpation: Trachea central; reduced expansion on right side
• Percussion: Dull note in right infra-axillary and infrascapular area
• Auscultation: Crepitations (fine, end-inspiratory) over right lower lobe; reduced air entry right lower zone; bronchial breath sounds right infra-axillary region

Cardiovascular System

• Heart sounds S1, S2 normal; no murmurs

Abdomen

• Soft, non-tender; liver 1 cm palpable below right costal margin (mild hepatomegaly, likely due to congestion/poor nutrition)
• Spleen not palpable

Central Nervous System

• Conscious, irritable but arousable
• No neck stiffness, no Kernig's sign
• Fontanelle: Closed (appropriate for age)
• Deep tendon reflexes: Normal

ENT

• Throat: mildly congested posterior pharyngeal wall
• Ear: No discharge, no perforation
• Nasal discharge: mucopurulent

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16. RELEVANT PUBLIC HEALTH / COMMUNITY ASPECTS

IMCI Classification (Park's PSM)

Government Schemes Status

Community Health Worker Contact

• ASHA: Savitri - referred the child to PHC after 2 days of fast breathing; counselling given on danger signs
• AWW (Anganwadi Worker): Was in contact but weight not plotted for 6 months
• ANM: Had visited the village for immunization camp 3 months ago; DPT booster not given (mother absent)

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17. PROVISIONAL DIAGNOSIS

Community-Acquired Pneumonia (Severe) - Right Lower Lobe IMCI Classification: Severe Pneumonia (based on chest indrawing + fast breathing + fever)

Moderate Acute Malnutrition (MAM) with Moderate Stunting Likely Iron Deficiency Anaemia (mild)

• Incomplete immunization (missed Hib - increases risk of H. influenzae pneumonia)
• Indoor air pollution exposure (biomass fuel + tobacco smoke)
• Overcrowding
• Maternal illiteracy and poor awareness of danger signs

Streptococcus pneumoniae (most common), H. influenzae type b (risk increased by incomplete vaccination)

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18. INVESTIGATIONS SUGGESTED

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19. MANAGEMENT PLAN

A. Immediate / Curative (IMCI - Severe Pneumonia Protocol)

• Admission to hospital (IMCI: chest indrawing = refer/admit)
• Oxygen supplementation (SpO2 94% - target ≥95%)
• IV/IM Ampicillin 200 mg/kg/day in 4 divided doses (first-line for severe pneumonia in this age group, per Park's PSM and Tintinalli's)
  • Alternative: Benzyl penicillin IV
  • If no improvement in 48 hours: switch to Ceftriaxone 50-100 mg/kg/day IV
• Antipyretics: Paracetamol 15 mg/kg/dose every 6 hours as needed (temp >38.5°C)
• IV fluids: Maintenance fluids (if oral intake inadequate)
• Oral feeds encouraged as tolerated; nasogastric if needed

B. Nutritional

• Therapeutic feeding: High-calorie, high-protein diet appropriate for age
• Vitamin A: 200,000 IU stat (single dose) - Akash has missed doses and is at risk of Vitamin A deficiency
• Iron-Folic Acid supplementation: Syrup ferrous sulphate (3 mg/kg/day elemental iron)
• Zinc: 20 mg/day for 10-14 days (reduces duration and severity of infection, per WHO)

C. Preventive (On Discharge)

• Complete pending immunizations (catch-up):
  • Hep B-3 dose
  • DPT-3 + DPT Booster
  • MR-2 (Measles-Rubella booster)
  • Hib vaccine (if available)
• Vitamin A prophylaxis: 200,000 IU 6-monthly till 5 years

D. Health Promotion / PSM-Specific

• Mother counselling:
  • Exclusive breastfeeding importance (for future siblings)
  • Complementary feeding at 6 months (not before)
  • Recognition of danger signs (fast breathing, chest indrawing, cyanosis = go to hospital immediately)
  • ORS and Zinc use for diarrhoea
• Father counselling:
  • Stop smoking indoors (bidi smoke = major risk for child's respiratory health)
  • Cooking area to be separated from sleeping area if possible
• Environmental: Improve ventilation in the home; use of smokeless chulha (improved cookstove) - Pradhan Mantri Ujjwala Yojana (LPG connection) to be availed
• Anganwadi: Regular attendance for supplementary nutrition and monthly weight monitoring
• ASHA follow-up in 3 days post-discharge, then weekly for 1 month

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20. PROGNOSIS

• Short-term: Good, if treated promptly with antibiotics and supportive care; expected clinical improvement in 48-72 hours
• Long-term: Guarded - risk of recurrence due to:
  • Persistent indoor air pollution
  • MAM/malnutrition (lowers immunity)
  • Incomplete immunization
  • Overcrowding
• Social prognosis: Requires sustained intervention through ICDS, ASHA follow-up, and mother's education

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SUMMARY (One-Liner for Presentation)

Akash, a 3-year-old male child from a lower socioeconomic rural background with incomplete immunization and moderate malnutrition, presents with 5 days of fever, 4 days of cough, and 2 days of fast breathing with chest indrawing; examination reveals tachypnoea (RR 46/min), right lower lobe dullness with crepitations, and SpO2 94%, with risk factors of indoor air pollution (biomass fuel + paternal smoking), overcrowding, and delayed/poor ANC; classified as Severe Pneumonia (IMCI) - right lower lobe, likely pneumococcal, requiring hospital admission, oxygen, and injectable ampicillin.

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