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ACUTE DIARRHOEA - SIMULATED CASE PROFORMA

PSM Practicals | MBBS (Community Medicine)

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SECTION A: PATIENT IDENTIFICATION

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SECTION B: CHIEF COMPLAINTS

• Loose, watery stools - 8 episodes over the last 24 hours
• Vomiting - 4 episodes
• Fever - since yesterday evening
• Decreased urine output - since morning

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SECTION C: HISTORY OF PRESENT ILLNESS

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SECTION D: PAST HISTORY

• Similar episode 3 months ago, treated at a local pharmacy (ORS given)
• No hospitalisation in the past
• No known allergies

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SECTION E: BIRTH & NEONATAL HISTORY

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SECTION F: FEEDING HISTORY

PSM Note: Inadequate breastfeeding and bottle-feeding are major risk factors in this case. Bottle-feeding increases risk of diarrhoea 10-fold due to contamination.

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SECTION G: IMMUNIZATION HISTORY

Immunization Status: Incomplete - Child has missed Measles vaccine, which is a known risk factor for diarrhoea-related morbidity and mortality.

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SECTION H: FAMILY & SOCIOECONOMIC HISTORY

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SECTION I: ENVIRONMENTAL & HOUSING HISTORY

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SECTION J: DIETARY HISTORY (24-HOUR RECALL)

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SECTION K: CLINICAL EXAMINATION

General Examination

• Child is irritable, crying
• Weight: 9.2 kg (expected for age: ~12 kg) - Weight-for-age: Grade II Underweight (IAP classification)
• Signs of dehydration (WHO Plan B):
  • Sunken eyes: Present
  • Dry mouth and tongue: Present
  • Skin pinch goes back slowly (>2 sec)
  • Child drinks eagerly/thirsty
  • Restless and irritable
• Dehydration assessment: SOME dehydration (Plan B)
• Pallor: Mild
• No icterus, no cyanosis, no clubbing, no oedema
• Temperature: 38.4°C (axillary)
• Pulse: 126/min, weak
• RR: 32/min
• CRT: 2.5 seconds

Anthropometry

Systemic Examination

• Abdomen: Soft, mild diffuse tenderness, hyperactive bowel sounds
• RS: Clear, no added sounds
• CVS: S1 S2 normal, tachycardia
• CNS: Irritable, no neck stiffness, no focal deficit

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SECTION L: INVESTIGATIONS

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SECTION M: DIAGNOSIS

Acute watery diarrhoea (ETEC) with some dehydration + Grade II Protein-Energy Malnutrition + Mild anaemia + Incomplete immunization

Acute secretory diarrhoea due to ETEC in a malnourished, partially immunized child with socio-environmental risk factors

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SECTION N: MANAGEMENT (WHO / IMNCI / National Guidelines)

Immediate (OPD/Inpatient - Plan B):

1. ORS - 75 mL/kg over 4 hours (Plan B) = 690 mL over 4 hours
   • Monitor every 30 minutes, reassess after 4 hours
2. Zinc supplementation - 20 mg/day for 14 days (reduces duration & recurrence)
3. Continue feeding - do NOT fast the child; resume normal feeds as tolerated
4. Anti-emetics if persistent vomiting (Ondansetron 0.15 mg/kg)
5. No antibiotics for watery diarrhoea (ETEC resolves spontaneously; antibiotics not indicated per WHO)
6. Treat anaemia: Ferrous sulfate drops + folic acid

Red flag signs - admit if:

• Persistent vomiting, blood in stool, signs worsening, severe dehydration

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SECTION O: PREVENTIVE & SOCIAL MEASURES (PSM FOCUS)

1. Individual / Family Level

2. Community Level

3. National Programmes Applicable

• IMNCI (Integrated Management of Neonatal and Childhood Illness) - for case management
• ORS-Zinc Programme under RNTCP/Child Health Division
• National Deworming Day - Albendazole 400 mg (after age 1 year)
• Poshan Abhiyaan - for malnutrition
• Swachh Bharat Mission - for open defaecation free status
• Jal Jeevan Mission - household tap water supply

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SECTION P: RISK FACTORS ANALYSIS (CHECKLIST FOR VIVA)

All 16 important factors from your proforma are covered in this case.

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SECTION Q: EXPECTED VIVA QUESTIONS & ANSWERS

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CLINICO-SOCIAL CASE: ACUTE DIARRHOEA

As per Rajkumar Patil - Community Medicine Practical Manual (Elsevier)

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1. IDENTIFYING DATA

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2. CHIEF COMPLAINTS

1. Watery loose stools - 8-10 episodes/day - since 1 day
2. Vomiting - 4 episodes - since 1 day
3. Fever - since 1 day
4. Decreased urine output - since this morning

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3. HISTORY OF PRESENT ILLNESS

• No blood or mucus in stools
• No abdominal distension
• No convulsions or altered sensorium
• Probable source: Child had street-bought cut fruits (mango slices) from a roadside vendor the previous afternoon

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4. HISTORY OF PAST ILLNESS

• Similar episode 3 months ago, managed with ORS at a local pharmacy
• No hospitalisation in past
• No chronic illness, no known drug allergy
• No contact with any known diarrhoea case recently (no outbreak in neighbourhood)

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5. BIRTH HISTORY

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6. FEEDING HISTORY

Significance: Inadequate EBF + bottle-feeding are major risk factors. Bottle-feeding increases diarrhoea risk 10-fold through contamination.

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7. IMMUNIZATION HISTORY

Measles vaccination missed - measles is an important risk factor for severe/prolonged diarrhoea

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8. DEVELOPMENTAL HISTORY

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9. FAMILY HISTORY

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10. SOCIOECONOMIC HISTORY

Family Profile

Socioeconomic Assessment (Modified Kuppuswamy Scale - 2026 updated)

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11. ENVIRONMENTAL HISTORY

(a) Housing

Overcrowding index: Persons per room = 9/1 = 9 (Normal: ≤3)

(b) Water Supply

(c) Sanitation & Drainage

(d) Refuse Disposal

(e) Personal Hygiene

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12. DIETARY HISTORY

24-hour Dietary Recall

Dietary Assessment

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13. PHYSICAL EXAMINATION

General Examination

• Conscious but irritable, crying
• Signs of dehydration (WHO/IMNCI assessment):

• Temperature: 38.4°C (axillary)
• Pulse: 126/min, regular, low volume
• Respiratory rate: 32/min
• CRT: 2.5 seconds
• No cyanosis, no oedema, no icterus

Anthropometric Examination

Systemic Examination

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14. INVESTIGATIONS

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15. DIAGNOSIS

Clinical Diagnosis

Acute watery diarrhoea (ETEC) with some dehydration

Medico-Social Diagnosis

Ramesh Kumar, a 2-year-4-month-old male child of a joint Hindu family belonging to Socioeconomic Class V, residing in an overcrowded kutcha house in a slum area with no household latrine, open-field defaecation, unprotected and non-disinfected water supply, and poor personal food hygiene - is suffering from acute watery diarrhoea with some dehydration, compounded by Grade II protein-energy malnutrition, mild anaemia, and incomplete immunization (BCG, Pentavalent 3, and MR vaccine missed). He was born preterm with low birth weight, received inadequate exclusive breastfeeding (only 2 months), and was bottle-fed from 2 months of age. His diet is grossly calorie-deficient and lacking in micronutrients. These social and environmental factors have created a background of vulnerability for repeated and potentially life-threatening diarrhoeal episodes.

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16. TREATMENT

Immediate Management (IMNCI - Plan B: Some Dehydration)

1. ORS - 75 mL/kg over 4 hours = 75 × 9.2 = 690 mL ORS in 4 hours Reassess dehydration status every 30 minutes; reassess fully after 4 hours
2. Zinc - 20 mg/day for 14 days (reduces duration, severity, and recurrence)
3. Continue feeding - do NOT restrict feeds; give frequent small feeds
   • Khichdi with oil, mashed banana with curd, rice with dal
4. Treat anaemia - Ferrous sulphate drops (3 mg/kg/day elemental iron) + Folic acid
5. No antibiotics - Acute watery diarrhoea (ETEC) is self-limiting; antibiotics not indicated per WHO/IMNCI

Danger signs - admit immediately if:

• Persistent vomiting preventing ORS intake
• High fever, blood in stool
• Signs of severe dehydration
• Altered sensorium

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17. PREVENTIVE AND SOCIAL MEASURES

At Individual/Family Level

At Community Level

Relevant National Programmes

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18. PROGNOSIS

• With appropriate ORS-Zinc therapy: Good for current episode
• Long-term: Guarded - risk of recurrent diarrhoea episodes due to persistent socio-environmental risk factors, ongoing malnutrition, and incomplete immunization unless social determinants are addressed

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19. FOLLOW-UP ADVICE

• Return for reassessment after 4 hours of ORS therapy
• Growth monitoring at Anganwadi every month
• Complete pending vaccines at CHC within 1 week
• Return immediately if danger signs develop
• Nutrition counselling for mother at next visit

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National Health Programs Related to Child Health

Explained with reference to your Acute Diarrhoea Case (Ramesh Kumar, 2yr 4mo)

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1. RMNCAH+N

• Full form: Reproductive, Maternal, Newborn, Child, Adolescent Health + Nutrition
• What it is: India's umbrella framework under NHM that brings all mother-child health programmes under one roof
• In your case:
  • Ramesh's mother had poor antenatal care → preterm birth, LBW
  • Child is malnourished (Grade II PEM) → Nutrition component (the +N) directly applies
  • RMNCAH+N ensures continuum of care from pregnancy → delivery → newborn → child → adolescent
• How to write in case: "The child and mother are beneficiaries of RMNCAH+N programme for nutrition rehabilitation and child health services"

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2. SAANS

• What it is: National initiative launched 2019 to reduce pneumonia deaths in children under 5
• Key interventions: Amoxicillin dispersible tablets at community level, early care seeking, Vitamin A, zinc
• In your case:
  • Ramesh is malnourished + incomplete vaccination → high risk for pneumonia
  • Zinc given for diarrhoea in your case also prevents pneumonia (dual benefit)
  • SAANS and diarrhoea management overlap: both involve Zinc supplementation and community ASHA-based care
• Remember: Pneumonia + Diarrhoea = 2 leading causes of under-5 deaths in India. SAANS addresses pneumonia; ORS-Zinc addresses diarrhoea

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3. Janani Shishu Suraksha Karyakaram (JSSK)

• Launched: 2011, under NHM
• What it provides (FREE entitlements):
  • Free delivery (normal + C-section) in government hospitals
  • Free drugs, diagnostics, blood
  • Free diet to mother during hospital stay (3 days normal, 7 days C-section)
  • Free transport (home → hospital → home)
  • Free treatment for sick newborns up to 30 days of age (extended to 1 year in some states)
• In your case:
  • Ramesh was born at home by an untrained dai → JSSK was NOT utilised
  • If JSSK had been used, institutional delivery would have ensured proper birth care, vitamin K, BCG at birth, early breastfeeding initiation
  • Write: "The family was not aware of JSSK entitlements. Counselling given regarding free institutional delivery and newborn care services under JSSK for future pregnancies"

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4. Khilkhilat

• What it is: National programme to address common childhood illnesses and improve child survival
• Focus: Reduction of infant and child mortality through improved home-based newborn care, nutrition, and management of common illnesses (diarrhoea, pneumonia, malnutrition)
• In your case: Ramesh's diarrhoea with malnutrition is exactly the target population
• Note: Khilkhilat works through ASHA workers at community level for early detection and referral

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5. Chiranjeevi Yojana

• What it is: Public-Private Partnership (PPP) scheme where private OB/GYN doctors are empanelled to provide FREE delivery services to BPL families
• Launched: 2005, Gujarat (later replicated in other states)
• Who benefits: BPL families who live far from government hospitals; private doctors compensated by government
• In your case:
  • Ramesh's family is Class V (BPL equivalent) - they qualify
  • Mother's next delivery should be under Chiranjeevi Yojana if in Gujarat, OR under JSY/JSSK in other states
  • Would have prevented home delivery → prevented LBW complications
• Exam point: Only mention if your college is in Gujarat OR as a model PPP scheme for maternal care

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6. Navjat Shishu Suraksha Karyakaram (NSSK)

• Launched: 2009, Ministry of Health
• What it is: Training programme for health workers (doctors, nurses, ANMs) in basic newborn care and resuscitation
• 4 core skills taught:
  1. Preventing hypothermia (warmth)
  2. Promoting breastfeeding
  3. Preventing infection
  4. Basic newborn resuscitation (bag & mask)
• In your case:
  • Ramesh born preterm (36 weeks), at home by untrained dai → no NSSK-trained personnel present at birth
  • Colostrum was discarded, prelacteal feeds given → poor breastfeeding initiation
  • Had NSSK-trained personnel been present: early breastfeeding initiation, warmth, infection prevention would have been ensured
• Write: "Mother to be counselled about importance of institutional delivery where NSSK-trained personnel are available"

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7. Newborn Care Corner (NBCC)

• What it is: A designated area set up in EVERY delivery point (PHC level and above) for immediate newborn care
• Equipment at NBCC:
  • Radiant warmer
  • Bag and mask for resuscitation
  • Suction device
  • Weighing scale
  • Vitamin K injection
• Services: Warmth, resuscitation, early breastfeeding support, birth weight recording
• In your case:
  • Ramesh born at home → no access to NBCC
  • LBW (2.2 kg) child born at home missed warmth care → risk of hypothermia
  • Preventive link: NBCC would have caught LBW early and initiated kangaroo mother care

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8. Newborn Stabilization Unit (NBSU)

• Level: Community Health Centre (CHC) - First Referral Unit
• What it is: A 4-bedded unit for stabilizing sick newborns before referral to higher centre
• Handles: Low birth weight babies (1500-1800g), mild-moderate birth asphyxia, jaundice needing phototherapy, feeding problems
• In your case:
  • Ramesh was LBW (2.2 kg) preterm → should have been admitted to NBSU at birth
  • NBSU would have provided: warmth (KMC), feeding support, monitoring
  • Distinguish from SNCU: NBSU handles moderate cases; SNCU handles severe cases

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9. Special Newborn Care Unit (SNCU)

• Level: District Hospital (DH) level
• What it is: A 12-bedded (or more) unit for sick and very small newborns
• Handles: Birth weight <1500g, severe asphyxia, sepsis, respiratory distress, severe jaundice
• Staffing: Paediatrician + trained nurses 24×7
• In your case:
  • Ramesh (36 weeks, 2.2 kg) born at home → if he had developed neonatal sepsis or severe distress, SNCU was the appropriate referral
  • Current visit: For diarrhoea at 2 years, SNCU is not applicable NOW, but was relevant at birth
  • Write in birth history: "Child should have been cared for in NBSU/SNCU at birth given preterm LBW status"

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10. IMNCI

• What it is: WHO/UNICEF strategy adopted by India for managing common childhood illnesses at facility level (PHC/CHC)
• Age group: 0-5 years
• Illnesses covered: Diarrhoea, pneumonia, malaria, measles, malnutrition, ear infections
• IMNCI approach (for diarrhoea in your case):

• Most directly applicable programme to Ramesh's case
• Write: "Child managed as per IMNCI guidelines for acute diarrhoea with some dehydration - Plan B ORS therapy initiated"

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11. F-IMNCI

• What it is: Extension of IMNCI for facility level (hospitals) - for children who are referred or admitted
• Difference from IMNCI:

• In your case:
  • Ramesh is managed at OPD level → IMNCI (Plan B)
  • If he deteriorates to severe dehydration → admitted → managed under F-IMNCI
  • F-IMNCI would apply: IV Ringer's Lactate (Plan C), monitoring, IV antibiotics if bloody stool/sepsis

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Quick Reference Card for Your Viva

KAP Assessment - How to Ask for Any PSM Case

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The Universal KAP Framework

KNOWLEDGE → What does the patient/attendant KNOW about the disease?
ATTITUDE  → What do they THINK/BELIEVE about it?
PRACTICE  → What do they actually DO about it?

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How to Frame KAP Questions - The Template

KNOWLEDGE Questions

"Do you know...?" / "Have you heard of...?" / "What do you think causes...?"

• What is this disease / what causes it
• How it spreads (mode of transmission)
• Who is at risk
• Signs and symptoms to watch for
• Where to go for treatment
• Government schemes/facilities available

ATTITUDE Questions

"What do you think about...?" / "Do you believe...?" / "Would you be willing to...?"

• Their belief about severity ("Is this disease serious?")
• Faith in modern medicine vs. home remedy vs. faith healer
• Willingness to change behaviour
• Stigma or misconceptions
• Acceptance of government services

PRACTICE Questions

"What do you do when...?" / "Do you regularly...?" / "When did you last...?"

• Actual current behaviour (hand washing, water purification, feeding)
• Health-seeking behaviour (where they go first - quack/PHC/hospital)
• Use of preventive services (immunization, ANC, contraception)
• Compliance with treatment

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KAP for Your Acute Diarrhoea Case (Ramesh's Mother)

KNOWLEDGE

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ATTITUDE

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PRACTICE

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KAP Summary Statement (Write This in Your Case)

"Assessment of KAP of the mother regarding acute diarrhoea and child health reveals poor knowledge regarding the role of contaminated water and food in causing diarrhoea, ORS preparation, and importance of hand hygiene. Her attitude is influenced by traditional beliefs - she stopped feeding the child during illness and prefers local quacks over government facilities. Her practices are poor - no hand washing with soap, no water purification, open-field defaecation, use of street food, and irregular immunization. Intensive health education was given regarding ORS preparation, hand hygiene, safe water, continued feeding during illness, and importance of completing the immunization schedule."

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Universal KAP Template for ANY Disease

KNOWLEDGE:
- Cause of [disease]
- Mode of transmission of [disease]
- Signs and symptoms / danger signs
- Treatment available (ORS for diarrhoea / DOTS for TB / ANC for pregnancy)
- Government schemes available

ATTITUDE:
- Perceived severity of [disease]
- Faith in modern medicine vs. traditional remedy
- Stigma (especially TB, HIV, leprosy, mental illness)
- Willingness to change behaviour / use government services

PRACTICE:
- Health-seeking behaviour (who do they go to first?)
- Preventive practices relevant to [disease]
- Use of government services (immunization / ANC / ASHA)
- Compliance with prescribed treatment
- Dietary and hygiene practices

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KAP for Other Common PSM Cases - Quick Reference

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Viva Tip

"I asked structured open-ended questions under three domains - Knowledge (what the mother knows about the disease, its cause, spread, and prevention), Attitude (her beliefs, perceived severity, and willingness to change), and Practice (her actual health-seeking behaviour, hygiene practices, and use of government services). Based on the assessment, I found poor KAP in all three domains and provided targeted health education accordingly."