Case module for Antenatal case:

Chief complaints:

-Amenorrhea
-Burning micturition
-Pedal edema
-Blurring of vision
-Giddiness, palpitation
-Bleeding p/v
-Discharge p/v
-h/o passing worm in stools
-h/o pica
History of present pregnancy:
o Conceived spontaneously
o Diagnosis of pregnancy –Time
o Registration - Time
o Whether booked case or not –Place (Govt., Private, Both)
o No, Of ANC Visits- table

Trimester 1:

 Excessive vomiting; Bleeding p/v; fever with rashes;

 Drug intake
 Weight gain -*
 Investigations-Hb; USG , blood group, VDRL, Hep-B,
 Folate supplementation *
 TT

Trimester 2:

 Quickening
 Weight gain
 Blurring of vision; epigastric pain; pedal edema; headache;
 Iron and calcium supplementation- whether taking daily or not *
  Side effects because of IFA supplementation-Nausea; vomiting; loss of
appetite; change in the colour of stools
 Hours of sleep/rest-afternoon and night
 Tetanus toxoid immunization
 Investigations-Urine albumin, sugar, microscopy; Hb*

Trimester 3:

 ANC visits; Weight gain

 Warning signs-
Pain abdomen;
Decreased perception of fetal movements;( Normal*)
Leaking / Bleeding pv;

Menstrual history:

 Menarche
 Regularity of the cycles
 Days of flow
 Excessive bleeding/clots
 Pain during periods

Marital history:

 Age at marriage
 Consanguineous/ Non-consanguineous
 Contraceptive usage

Obstetric history:
Obstetric score-

Sl Type of Place of Sex and Post natal: Feeding history Present status
no Delivery delivery weight Fever; Time of starting; Immunisation
Whether Foul Prelacteal feed; and
cried smelling Duration of EBF; nutritional
immediately lochia: Complementary status
or not Bleeding feed started
pv;

Dietary history: 24 hr recall (PEM Table)

Type of diet-

Salt and Fat Intake-

h/o increased /decreased intake of food than pre-pregnant period- ( KABP)

Past history: HTN; DM;TB; Blood transfusion

Family history: History of twins; preterm

General physical examination:

 Pallor
 Pedal edema
 Breast
 Thyroid
 Spine

CVS:

RS:
Abdominal examination:

Inspection:

 Shape of the abdomen

 Symmetry
 Fullness of the flanks
 Striae gravidarum
 Scar
 Hernial orifices

Palpation:

 Fundal height
 Symphyso fundal length
 Fundal grip
 Umbilical grip
 1pelvic grip
 2pelvic grip

Auscultation:

 FHS

Interventions -

-ICDS-Anganwadi centre: awareness and utilization-reasons for non-utilization

-Preparation for delivery-Money, vehicle, decision about place of delivery

-Advice regarding abstinence during last Tt ? of pregnancy and 6 weeks after

delivery

-Plan for family planning-contraception

-Advice to continue IFA for 3-6 months after delivery

 ANC

1. Essential obstetric care, Emergency obstetric care

2. NFHS-3 –Maternal health indicators-Table
3. Weight gain during pregnancy- (by trimester/month/week)
4. Methods of hemoglobin estimation-Sensitivity & specificity-table
5. Requirements during pregnancy and lactation (first 6 months & later)-Table
a. Calories
b. Protein
c. Iron
d. Calcium
6. Classification of Anemia (table) & Cost and iron content of iron tablets, syrup (common brands-
Hematrine, Autrin, Haeme-up)
7. No of ANC visits ideal and minimum
8. Diagnosis of PIH, Eclampsia, Gestational Diabetes, PPH
9. Danger signs during pregnancy
10. Different ways of calculating POG
11. High Risk pregnancy-List & proportion of HRP
12. How much rest/sleep should be advised for a pregnant woman?
13. Rh-isoimmunisation-Diagnosis and Management
14. Management of PPH (WHO)
15. Treatment of malaria during pregnancy
16. Worm infestation- treatment during pregnancy
17. JSY –Eligibility & cash assistance-LPS/HPS states-table
18. Eligible couple-Definition
19. Advice regarding Contraception-first 6 months of lactation
20. LAM-Criteria
21. MDG –related to Maternal health
 Must know points in CPSC during 1st Clinical Posting

• Family, types of family, different SES scales

• How to calculate SES using Modified Kuppuswamy and Prasad scale

• Environment related concepts

– Safe water
– Overcrowding etc..

• History, examination and diagnosis including KAP and psycho social aspects

• Clinical diagnosis and family diagnosis- difference

• Diet history

• Anthropometric measurements and BP measurement

Must know areas under ANC & PNC

– Essential obstetric care, Emergency obstetric care

– High risk pregnancy

– Things to do at first ANC visit

– ICDS

– Extra calorie and protein requirement

– History relevant to Post-partum sepsis/puerperal sepsis

– IMNCI assessment of newborn

Must know areas under U-5

– IMNCI flow charts, with focus on

• Classification of diarrhea and ARI

• Growth charts

• Immunization schedule

• Breast feeding history

 – Diet history, milestones

– ICDS

Must know areas under Diabetes and Hypertension

– Diagnostic criteria of diabetes, pre-diabetes/HTN/pre-hypertension

– Risk factors for diabetes/HTN

– History related to complication of diabetes/HTN

– Interpretation of anthropometric indices- BMI, WHR, WC, Hip C

– DASH diet, dietary modifications in diabetes patients

– Frequency of follow up visits and investigations

Must know areas under Tuberculosis

- Definition of TB suspect and diagnostic algorithm of TB

- Define

o Treatment Failure

o Relapse

o Cured/completed

o Treatment after default

- Initial defaulter

- Method of disposal of sputum

- Side effects of ATT

- Timing of follow up sputum exam

- Chemoprophylaxis

- Treatment card, Patient identity card

 bTUBERCULOSIS QUESTIONS

1. Demographic characteristics:

SL Name and Age Sex Education Occupation

No Relation to the (years) status
index case

Socio economic status (Kuppuswamy classification)-

2. History of presenting complaints:

a) Presenting complaints-
b) Duration of cough- *
c) Expectoration-
d) Hemoptysis-
e) Evening rise of temperature-
f) Weight loss-
g) Loss of appetite-
h) Lymph node enlargement-
i) Presence of any sinus/fistula-
j) Discharge-
k) Any deformity/pain/rigidity in any joints-
l) Headache/nausea vomiting/neurological symptoms-

3. Past history:

a) H/o contact –Neighbor/family/work place-

b) H/o Diabetes mellitus-
c) H/o HIV/AIDS-
d) H/o BCG vaccination-

4. Treatment history:
 a) First contact person for the above complaints-
b) When was the sputum examination done-
c) Place where the sputum examination done-
d) When did you receive the results-
e) Other investigations – CXR, Montoux test –
f) Duration between diagnosis and start of treatment-
g)
h) Treatment duration till now-
i) Any injections-
j) On what dates received treatment-
k) Follow up sputum-
l) Compliance-
m) Side effects- Jaundice/loss of appatite/red coloured urine/rash/
n) Weight before the start of treatment-
o) Present weight -
p) Previous treatment h/o for the same condition-No of times/Duration/Place-

5. Personal history:

a) Alcohol
b) Smoking/pan chewing/
c) Menstrual h/o(females)-

6. Social aspects:

a) House layout-
b) Method of disposal of sputum-
c) KABP assessment-
d) Under five child in the family-
e) Chemo prophylaxis for the under 6 child-

7. General physical examination:

Presence of BCG scar-

8. Examination of the lymph nodes:

a) Inspection
 o Situation, Size of the swelling
o Shape
o Redness
o Skin over the swelling
o Sinus/fistula

b) Palpation

o Tenderness
o Rise in temperature
o Consistency
o Matting

c) Presence of other swelling in the body

9. Systemic examination:

10. Impression:
 Tuberculosis

1. Objectives of RNTCP
2. Numbers/Proportions
a. Incidence/prevalence of TB disease
b. Lifetime risk of getting TB in general population
c. MDR TB in new cases/retreatment cases
d. TB in HIV patients
e. HIV in TB patients
f. Proportion of Defaulters
g. Mortality rate in TB
3. Steps in Acid-fast staining
4. Evolution of BCG scar (BCG scar reaction)
5. Categories and color coding-table
6. Non-DOTS regimen
7. Components of DOTS
8. Diagnostic algorithm of TB
9. Define
a. Treatment Failure
b. Relapse
c. Cured/completed
d. Treatment after default
e. Initial defaulter
10. Stop TB strategy
11. Method of disposal of sputum
12. Side effects of ATT-Table
13. Second line of drugs-list
14. MDR TB-Definition
15. Who is “MDR TB suspect”?
16. Management of MDR TB-Table
17. XDR TB-Definition
18. List of NRLs
19. Copy of Treatment card, Patient identity card
20. Timing of follow up sputum exam
21. Chemoprophylaxis
22. Pediatric ATT boxes-color code/dosage
23. International Standards for Tuberculosis care (only points/headings)
24. MDG goal –related to TB
25. Broad Structure of RNTCP Network
26. Criteria for DMC
 Clinico Psycho Social Case Review
Case of Protein Energy Malnutrition: Proforma

Head of the Household:

Age:
Sex:
Religion:
Caste:
Address:
Migration: from duration
Reason for migration:
Details of the family:
Sl no Name Age Relation to HoH Education Occupation

Socio economic status:

a) Occupation (in case of retired person last occupation he was engaged in)
 Ask about the nature of work
 whether in govt or private sector
 availing any social security schemes
b) Education
c) Family income
Socioeconomic status:
Per capita income: (APL/BPL)
(urban Pondicherry cut off for BPL)
Enquire about the ration card

Index case:
Informant: Reliability:

Chief complaints: Failure to gain weight since___________

Any other complaints

History of presenting complaints: Elaborate the chief complaints. Enquire about other
complaints.
Ask about h/o
 diarrhoea
 recurrent infections(respiratory and skin to be specially enquired)
 worm infestation
 decreased appetite
 chronic conditions especially TB
  Ear discharge

Ante natal, natal and Post natal history: Trimester wise history 1st, 2nd and 3rd. Weight gain
during pregnancy, increased food intake during the pregnancy.
Complications during pregnancy like
 hyperemesis
 pre eclampsia
 eclampsia
 infections
 pre term delivery
 ante partum hemorrhage
Investigations done during pregnancy:
 Hemoglobin estimation,
 blood grouping,
 ultra sound scanning.
Mode of delivery, timing, place of delivery, birth weight, complications at the time of birth, cry
after birth, time of starting breast feeding.

Developmental history:
a) Gross motor
b) Fine motor
c) Language
d) Personal social

Immunisation history: vaccines given appropriate for age, BCG scar, (reports of immunisation
like immunisation card to be seen), ascertaining whether measles vaccine and vitamin A given,
delay in immunisation and the reason for delay, optional vaccine administered.

Nutrition history:
 time of starting breast feeding after birth
 duration of breast feeding both exclusive and total
 h/o of administration of pre lacteal feed
 time of complimentary feeding and started with what
 whether child given any commercially available preparation
24 hour diet recall:
a) Breakfast
b) Lunch
c) Evening snacks
d) Dinner
Calories and protein calculation:
Required
Actually consumed
Deficit

Treatment history: undergoing any treatment for chronic condition, for the present condition,
h/o treatment in the past, past hospitalisation.
Family history: h/o chronic condition in the family especially tuberculosis, h/o other children of
the family, h/o contraception usage by the couple.

General physical examination:

Evaluation of pallor, icterus, cyanosis, clubbing, pedal edema, lymphadenopathy.
Anthropometry:
Parameter Observed Expected Deficit
Weight
Height
MUAC

Head to toe examination to look for evidence of PEM like fontanneles, eye changes, skin
infections, dermatosis, hair changes, nail changes, signs of rickets like pot belly, wrist widening,
richaty rosary, harrisons sulcus, bow legs, knock knees. Oral cavity examination for dental
hygiene and assessing dentition.

Systemic examination:
a) Cardiovascular system
b) Respiratory system
c) Per abdomen
d) Central nervous system

Environmental history:
a) Housing: type, no. of living rooms, no. of persons, overcrowding,
b) Ventilation:
c) Lighting
d) Drinking water: source, storage, method of retrieval.
e) Personal hygiene: frequency of bathing, brushing teeth, cutting nails, practice of wearing
chappal.
f) Sanitary latrine: present/absent
g) Waste disposal:

KAP study:
a) Importance of weight gain
b) Vaccination and supplementation
c) De worming
d) Anganwadi and supplementary nutrition
e) Method of preparing ORS
f) Home available foods
g) Health seeking behaviour
h) Recognition of danger signs

Family diagnosis:
 type of family
 SES
  APL/BPL
 Grade of PEM
 Status of immunisation
 Disease if any
 Eligible couple
 Social problem

Web of causation:

Interventions:
a) Immediate: clinical management of any existing condition, de worming, dietary advice.
b) Long term: personal hygiene, vaccination, vitamin prophylaxis, nutritional advice, weight
monitoring, anganwadi service utilisation, family planning choices, importance of birth
spacing.

PEM/Under-5 Child

1. Socio-Economic status Scales

i. Modified Kuppuswamy Scale, Prasad Scale
ii. Occupational classification in Modified Kuppuswamy Scale
2. BPL criteria (India, Pondicherry)
3. Child health indicators from NFHS-3 (table from fact sheet) & MDG –related to Child health
4. Proportion of infants, under-3, under-5 and <15 yr age group
5. Proportion of infant deaths,under-5 deaths out of total deaths
6. IMR,NMR,U_5 mortality rate, early NMR (India, Pondicherry)
7. Definitions for Diarrhea, Management, Different types of ORS –composition (gms/mmols)
8. How to make ORS at home?
9. Prevalence of diarrhea /ARI as in NFHS-3
10. Developmental milestones
11. National Immunisation Schedule/IAP schedule to cover optional vaccines
12. Differences between breast milk and cows milk
13. What is full cream milk, toned milk, double tined milk? Cost and calorie content?
14. Calorie and protein requirement 0-5 yrs-Table
15. Dentition
16. PEM classifications (New WHO, IAP, Gomez, Waterlow, Welcome trust, age independent
anthropometric indices)
17. Signs & symptoms of Vitamin Deficiencies
18. Vitamin A –Prophylaxis and Treatment
19. Growth charts-WHO,ICDS, UHP-growth chart used in our area
a. No of curves-interpretation
 b. Reference population for uppermost and lowermost curves in each chart
20. Danger signs-ARI/Diarrhea (IMNCI)
21. Management of SAM (WHO guideline/IAP guideline)
22. “At risk” infants
23. Vit-D deficiency-Treatment
24. IMNCI management charts