HISTORY AND EXAMINATION : PNC PERFORMA : Aryan Arora, 2018 Batch
HISTORY:
Hind
I am presenting the case of Mrs ______________, _____
23 year old female belonging to __________
th
12 Badarpur
religion, Educated up to ________ resident of ______________ /W by occupation. She is
and ________
Sameer
married to ______________ smouther years, who is Wifi
for _______ agent by occupation and has Educated up to
_________
.
the
________. According to the Modified Kuppuswamy scale, she belongs to ________ Class.
12
at August 2028 ~
S
us
She is PLA and today is her PP Day of FTNVD/FTCS Delivery/ Preterm Delivery/ Elective CS/
num
Vacuum Delivery done in view of .
3
-
4 suddoc which makes her EDD __________. (EDD = 280 days or 40 weeks or 10
Her LMP was on __________ -
dans Lunar months; Only 4-5% deliver but if we do +-1 week => 80%) If Irregular cycle=> Add the Extra weeks
-
de or Subtract the Less weeks. G= P+ L+1 (If PATIENT IS NOT PREGNANT => We say PLA). Her POG on the day=
of delivery was _______________
period -
She is a booked/registered patient(Registered on 3 With at ______) or unbooked and presented to the
_______
HAHC hospital __________days back, with the chief complaints of :
1. __________ month Amenorrhea
2. ___________ x days/week
3. ____________ x days/week ( If no chief complaints then, presented for normal routine checkup)
&
J
Immuth ↑ 1
[
① Pain >
- X
pue
3
-
HOPI
>
-
Ruability to pac wine
Shoulder back
3 Post part un
② Fever >
- si muth
.
According to the patient, she was amennorhic for past ______ days when she developed : PLEASE ALSO
TAKE NEGATIVE HISTORY D
↓
Most common complaints UTI -
y bath.
Foley
1. Leaking PV ↓
tub
2. Abdominal pain *
3. Decreases Fetal movement on
need
4. Completion of term -
Labour course
She had occasional contractions every 30 mins lasting 30s, starting on _______ (date) at ____ (time)
which gradually increased in duration,intensity and frequency and when pains started occurring every 5
brolle 18th 19 : 30am]
water -
Aug
= -
-
Admitted >
-
A ph camera .]
12pm
mins patient visited hospital at ______.ROM occurred at _____.The pains were allowed to progress
spontaneously. The patient was shifted to delivery table at _____ and within _____ hrs, the patient
of 2 61g (date) at
delivered with the help of an episiotomy a ______ (sex) ______ weighing baby on _______ .
5 10 am (time). The baby cried immediately after birth. -
________
:
*
> The placenta was delivered ________ after delivery of baby and mother shifted to bed after stitching
-
episiotomy. Baby breastfed ______
3 his mins after delivery .
2-
↑
No delivery related complications
X If C section was done, Write
1.Anaesthesia
2.Duration of C section
3.Complications during C section
Immediate Post Partum course Tours
L
She passed urine after 2 3 hrs of delivery and was shifted to ward after hrs of observation.
-
~Patient is ambulating well on Oral analgesics.
2
-
3
She has been passing bright red/ brown colored discharge PV and has been using N pads per day
= =
Post C sec Y
Foley’s was removed after _____ hours.Liquid was allowed after ____ hours, Semisolid food was allowed
after ______ hours and Full Oral diet was allowed after ______ hours.
She passed urine after hrs of delivery .
She has been passing bright red/ brown colored discharge PV and has been using pads per da
She is ambulating well on oral antibiotics/analgesics
Total G
L T
HOPP ( History of Present Pregnancy)
lothan
1st Trimester ↓ -
-
Her current pregnancy was planned/spontaneous and was confirmed by herself/doctor with the help of
-
UPT at _______ weeks of gestation. March 2018
Lom Dec 1
-
.
-
N
She presented to the hospital for the first time at _____ 2
weeks and has ______ no of total ANC visits.
Most common complaints :
Not: Nausea /Vomiting ( d/t Increased B HCG which peaks at 9-11 weeks)
Investigating : Investigations done : USG at ______
16 weeks whose results were ______
*
F: 1. Fever w Rash ( TORCH infections) _________
*
-
2. Folic acid supplementation ( 500 mcg/day) _________ ( No Iron as it can lead to excessive Vomiting)
&
R: Radiation exposure if any ___________
Y
A: Abortion ( Spontaneous or threatened) thus leading to Bleeding __________
--
. (Not
2
U: Urine frequency increased ( mc : 8-10 times) ________ reported
- -
-
-
D: Drug history( eg HT/ Thyroid problems/Diabetes)
Blood group ( For Rh negative )
Anemia or Not a s
-
-
- -
*
2nd Trimester
1. H/ O Quickening( Normal in Primi = 20 weeks and in Multi = 16 weeks; Normal Fetal mov/ day is 10) (
Feathery movements/fluttery movements/bowel movements ) at ______ 6 months
X
2. Increased Urinary frequency and Burning micturition ( UTI) ________
3. Td dosing ( Current guidelines : Give First dose ASAP( @ 1st ANC visit). Older guidelines : First dose :
16-20 weeks and 2nd Dose 20-24 weeks with MINIMUM ONE MONTH GAP. In case of H/O Immunisation(
am much town-repeat
< 3 years) , Boster Td is given which imparts protection of 5 years. ) ___________ .
~
4. Iron ( 60 mg) and Folic acid ( 500 mcg) ___________
-
5. Calcium (500 mg BD): ________ simuhy Y
24 weeks and report was ________
6. USG done ( TAS= Targeted anomaly scan/ Level 2 USG) @ _______
-0 16
7. Screening for GDM done ( mc test = Oral GTT)@ ________
nxh
weeks and report was ______.
8. Drug intake _________
used at night)
o
9. H/O
--
Headache, Blurring of vision, Epigastric pain , Seizures, Edema( Asked as Tightening of rings) =
E
Preeclampsia/ Eclampsia)
10 .
-
mig- 86
*
F -
noth
O-190
each
10. Weight gain : ( Normal = 9-11 kg gain ; After 1st trimester, 2kg weight gain/ month; If< 2kg/month :
Inadequate diet => Lead to IUGR => LBW baby >3kg/ month : DM/Twins/Preeclampsia
11. Other complication:
3rd Trimester
1. Fetal movement felt at -
G
2. Increased Frequency of Micturition:
⑦
3. Bleeding _________
while
4. Discharges _________ discharge .
505. Itching ( Increased
- -
Estrogen => Increased Conj Bilirubin => Bile stasis)* re discharge
-
the
O
6. Abdominal pain : ________
-
↓
??
7. Lightening/ Dropping : _________ sport, resolve
- dang
.
8. USG done @ _______ with reports ________.
9. Nausea/Vomiting _______
Menstrual history
LMP : __________ and POG _________
28
L : Length of cycle _________
R2yrs
M: Menarche age ________
3
NO : NO of days till which bleeding lasts ( Checking for Menorrhagia or Menometrorrhagia) _________
& 2B
P: Pain( Dysmenorrhea) ________ Pads used ( Amount of Bleeding) : _______
Y
Q: Qlots( Clots) or any other associated symptom( eg Lower back pain) _________
-
R: Regularity __________
Obstetric history :
M
w
She is married for- Dia years and it was a consanguineous/ Non consanguineous marriage.
______
GPLA ________
to
?!
(
S No. DOB ANC visits POG Mode of Place of Conducted Outcome Sex Weight Baby @ Complicatio
-
Delivery Delivery by Birth n during
m
Cried Labour/
APGAR Puerperium
Breast Fed
[ Immunisatio
n
1stAng 5-6 UC .
Hospi / of 2019-
Y
HO Previous pregnancy :
&
Conceived after _______ months/years of marriage.
She was a booked/ unhooked patient and delivered at ________ Weeks by_______ NVD/ C-
section in _________ Hospital.
Baby was ____ kg in weight, Male or Female who cried immediately after birth.
“If NVD”
She went into labour spontaneously/ vh of labour was done which lasted for ______ hours and
a female/male child of ___ Kg was delivered who cried immediately after birth.
Antepartum, Intrapartum and Postpartum period was uneventful.
Breast feeding was initiated after ____ hours and continued till ____ year /months.
He/she is Fully immunised till date.
The baby is _____ year old presently, alive and well.
Contraception __________
HO Abortion
Conceived after _______ months/ years of marriage, which resulted in Medical or Spontaneous
Abortion at ______ weeks POG ______ years ago due to ________.
TREATMENT HISTORY ( Including contraceptive use)
Past Medical history:
She is a known case of _______ and is on ________ ( Medication).
-A) Medical : DM/HT/Heart Disease/ Thyroid/ TB / Asthma/ Epilepsy/ STDs/Bleeding disorders
vB) Surgical : 1. General : Appendectomy/ Cholecystectomy/ Hernia/ other
- - - -
-
2. Gynaecological: DNC, Myotomy etc
m Dec 2023
C) Blood transfusion- & -
yech-
In
=
uTI
-
S &
Yay
>
-
Family history
Personal history: -
1. Diet : According to the 24 hour recall method, her calorie intake is ________.
O anide -
2. >
Veg/Non -
veg/ vegan
3. Smoking AND Alcohol -
4. Drug addiction v
5. Bowel and bladder
-
6. Allergy
-
7. Sleep >
- 7-8hV -
EXAMINATION :
1. General physical examination:
The patient is lying comfortably in bed in supine position with an empty bladder. She is conscious,
well oriented with time, place and person and has average/healthy/lean built.
I) Basic Physical :
X
P: Pallor ________·
X
I: Icterus _________
Y
C: Cyanosis ________
Y
K: Klubbing ________
OL: LN+ _________
X
Y
E: Edema _________
Orodental hygiene ( Lips and Tongue) :
-
Thyroid:
um
& Gait:
II) Anthropometry
8 / -
Height ________ Weight _______ BMI ________
mu
III) Vitals --
62
1. Pulse ______beats/min( Normal : 60-90 b/min) regular in rate and rhythm, good in volume, equal
in both
-
sides with palpable peripheral pulses and No Delay in sitting position.
-
126176
2. BP : _________mm/hg sitting
in _______position in right/left Brachial artery.
O3.accessory
RR: _______/min which is Thoracoadbominal or Abdominothoracic with or without use of
muscles. ( Normal : 18-20 breaths/min)
O
4. TEMP: _______ Degree C or Degree Fahrenheit Measured at _______
O
5. Jugular Venous Pressure _____ cm of blood/water above sternal angle (+ 5 cm water from right
atrium)
2. Breast examination:
M : Masses/lumps
Breast)
A: Asymmetry
N: Nipple changes : Nipple Inversion Nipple discharge
S: Scar Marks ( Indicative of Prev Surgery)
Skin : RUBOR( Redness )= Erythema DOLOR : Pain = Tenderness TUMOR : Swelling = Paeu D'orange
If Normal, Breast Bi laterally Symmetrical, With No Lumps, Discharge, Scar marks and Normal skin
with Erect Nipples.
3. Systemic Examination:
A) CVS : S1/S2 heard
B) Respiration : Trachea centrally placed with Normal breath sounds and No added breath sounds,
C) Neurological examination
D) Abdominal examination:
PRE REQUISITES:
1. Examiner stands at Right side.
2. Bladder should be empty
3. Mother : Supine with Knees flexed
PNC SPECIFIC
[
Uterus : Bulge in the abdomen, Contraction of Uterus ( Involution of uterus)
Just after delivery it is 20 weeks Uterus (Lower border of Umblicus)
PP period:
1st day
-
● Urine/Stool passed
-
● Amount of bleeding -
● Temp (Twice daily) -
● Feeding baby
● Vomiting
● Headache
● Abd Distension -
In CS, after hearing the bowel sounds, allow patient to eat orally
INSPECTION:
● Abd Distension
● Scar : Length and breadth, Longitudnal or transverse, distance from PS, Inflammation
● Soakage of dressing with blood
● Wound infection
● Gaping
LOCAL:
LOCHIA
● - Excessive)
(Normal/
● Color medish + Brown
● No of pads 2 3-
● -
Smell (offensive/ foul)
BREAST EXAMINATION: same as above.
2nd Day
Same as Day 1. Bowel sounds need not be heard again
O/E
● Abd soft, no distension ab I
● Well contracted uterus at the level of umbilicus
● No tenderness
● Lochia ①
● Ask the patient the following a)Passed flatus -
b)Voided urine X
c)Any fainting episode X
3rd Day
● Temp
● Br. Examination: In case of engorgement, ask mother to express milk manually
● Ask about the passage of stools
4th Day
● Temp
● Remove dressing of the CS
● Scar Exmn.
a) Induration
b) Discharge
c) Bleeding
d) Abd Examination
● Uterus
● Breast
● Lochia
5th Day
Day 4 investigation+ Calf muscle tenderness (Indicates thrombophlebitis and DVT)
6th Day
Same as Day 4
7th Day
Remove stitches + Day 4
Patient is discharged on Day 4 in FTNVD or Day 7 in LSCS
PERINEUM EXAMINATION
● Undue bleeding
● PV/ Vulval hematoma
● Color and nature of lochia
● Episiotomy wound infection/ gaping; REEDA scoring : Redness,Edema,Ecchymosis,Dishcharge,
Approximation)
●
in mother's
EXAMINATION OF BABY
-
seeping lap
● Baby conscious, lying on bed/mother’s lap (If at NICU, tell the Indication and details)
● HR= /min
● RR= /min
● No visible gross congenital anomaly
● Urine passed2 hours after delivery
● Stool passed hours after delivery
● Immunised with OPV-0/BCG/HepB-0 -
● Breastfeed a)Started how many hours after delivery 2 3 his
-
b)Frequency 6-8/d Leury 23 hrs]
c)Night feeds
5-6/20-30 min
ON EXAMINATION
a) Umblical stump appears healthy and healing without blood or pus discharge
b) Forceps or vacuum mark over head
c) Cephalhematoma/Caput succedaneum
SUMMARY
A Yr old female PLA with a FTNVD/LSCS delivered a male/female baby, PP day with no
maternal or fetal complications with uterus involuting and a healthy episiotomy/LSCS wound
