Index case presentation in psm

Index case presentation in psm

Index case is very important in psm practical. So make sure that you prepare it correctly. So, here is given the perfect way of index case presentation in psm.

Must read  -- How to prepare for psm practicals

Before you read this article, read -- Family presentation in psm

You can get any of the Case like under 5, adolescent, geriatric. Here is the case presentation of under 5 year child.


I'm presenting the case of ____ year old child named ________ , resident of _______ (address) born on _________ (date of birth) at _____ AM/ PM.

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Chief complaints

Write all the complaints that the index case presents.
Example, Cough × 7 days

History of present illness

Write details of chief complaints

Example,   Cough - Sudden in onset
Non progressive in nature
No aggravating factors
Relieved by medication
No associated features
No diurnal and postural variation
Dry cough with no sputum
No history of night sweats

Past history

No history of similar complaints
No h/o tuberculosis, Asthma, diabetes mellitus, hypertension, epilepsy.
No h/o drug intake/ iron supplements.

Birth history

• Birth took place at ___________ hospital.
• Delivery done by _______ ( doctor/ nurse ..) on _______ ( date and time of birth) and was _______ ( normal/ done by c section)
• Birth weight ______
• H/o immediate cry ( absent/ present)
• Breast feed started at ___th day and stopped on ____ ( or continued till now).
• Prelacteal feed was _____ ( given/ not given) ( if given, specify it) ( ex, powdered milk for initial 2 days)
• Birth order _____.
• Delivery was full term.

Immunisation history

Immunisation status is complete for year
Immunisation card present ( take photocopy of immunisation card)

Development history

Developmental milestones are normal till age. ( Write all the gross motor, fine motor, social adaptive milestones achieved).

Family history

No h/o hypertension, asthma, tuberculosis, epilepsy, diabetes mellitus.

General physical examination

Patient is concious, cooperative and  moderate build
Pallor         -nt / +nt
Icterus       -nt
Clubbing   -nt
Edema       -nt
Cyanosis    -nt
Lymphadenopathy   -nt

Vital parameters

Pulse  _______ bpm
Temperature ________ °f
Respiratory rate _____ breaths/min
Blood pressure  _______ mmHg

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Anthropometry

Height  _______ cm
Weight ________ kg
Head circumference ______ cm
Chest circumference _______ cm
Mid arm circumference ______ cm

Expected weight of child
You can check wheather the child has appropriate weight according to his age by these formulas

3- 12 months,  Age in months + 9
                                        2
1- 6 years,       Age in years × 2 + 8
6- 12 years,    Age in years × 7 - 7
                                       2
    OR.              Age × 3 + 1

Expected hieght of child
Upto 12 years,  Age in years × 6 + 77

Remember that for vivas, the table of weight and height is doubled / trippled in which year is v. Imp.

Head to toe examination

Hairs                - Normal
Eyes                  - N
Conjunctiva .   - N
Skin.                  - N
Lips                   - N
Tongue              - N
Face                   - N
Gums                 - N
Oedema            - N
Teeth.                - N

Systemic examination

CVS
S1 S2 normal
No murmur heard
Chest bilateral equal air entry
No added sound heard

Per abdomen
No palpable organomegaly

CNS
No abnormality detected.

Family pedigree

You have to make pedigree of your family like this

Dietary history of family

( 24 hour day recall method)

You have to make 2 tables in this format by asking about the food consumed by the family in last 3 days.

Next, make a table showing amount of calories and protein consumed.

Calories total  = 20738.9 kcal
Proteins           = 690.69 kcal
Consumption unit =  87
 (1 consumption unit = 2400 kcal/day)
Calories per CU    =  2383.78 kcal
Proteins per CU   = 79.38
% excess calories = 2.7 %
% excess protiens = 32 %

Remember,
100 gm wheat has 342 kcal, 12g protien
100 gm rice has 342 kcal, 6g protien

Dietery history of index case

You have to make 2 tables for index case also in this format

Next make a table showing the amount of calories and protiens consumed by index case

Required calories = 1060 kcal/ day

Calories deficit      = 173 kcal

% calories deficit  = 16.3 %

Required protiens  = 16.7 g/ day

Protiens excess        = 7.5 g

% protiens excess   = 45 %

Growth chart

Make sure you prepare growth chart of your index case because it carry extra marks. Measure the weight everytime you visit the family and plot it on growth chart. Check that how is the growth of child occuring.

Socio clinical diagnosis

A ____ year old ____ (male/ female) child of birth order ____ with normal growth and development and normal anthropometric and developmental milestones is taking adequate diet.

Problems that can be solved 

Write all the problems in your family and index case that can be solved like 

- use closed dustbin

- maintain proper cleanliness

- using exhaust fan

- Relationship with neighbours

Problems that can't be solved  like

-Poor street lights

- No cross ventilation in rooms

- Poor ventelation of rooms

- Overcrowding

Suggestions at individual level, community level and family level.

You have to write what suggestions you will give to them at 3 levels for thier betterment.

Must read -- Important viva questions in psm

So this is the ideal index case presentation in psm. Hope that it helped you.

So, all the best for your studies.

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