COMMUNITY CASE [PNC]

Demographic Data
Name:

Age:

Gender:

Address:

Occupation:

Education:

Husband’s Occupation:

Husband’s Education:

Total monthly income of family:

Socioeconomic Status: Kuppuswamy’s S/e status scale

Occupation score=

Educational score=

Total monthly income score=

Total score=

Marital Status:

Date of Admission (DOA):

Date of Examination (DOE):

Last Menstrual Period (LMP):

Estimated Date of Delivery (EDD): By Naegele’s Formula [(LMP + 7 Days) – 3

Months + 1 Year]

Date of Delivery (DOA):

Date of Surgery (DOS):

Chief Complaint:
Associated Complaints:
HOPI:

Pain History:
1) Onset:
2) Site of pain (with diagram):
3) Duration of pain:
4) Quality of pain:
5) Provocating Factors:
6) Relieving Factors:
7) Temporal Variation:
8) Intensity of Pain: {NPRS- Numerical Pain Rating Scale}

At rest

During activity (mention activity)

 Obstetric History:
Marriage Life:

Age At Marriage:

Consanguinity Marriage: Yes/No

If yes then degree of consanguinity -

Contraception Used: Yes/No

If yes then the type of contraception used -

No. of Age Gender Delivery method Weight of Immunizatio APGAR

babies the baby n score

1.

Any Period of Infertility:

Relation with Partner:

Gestational Period:

Obstetric Index: G P A L D

 Baby:
1) Type of Delivery –
2) Sex-
3) Age-
4) Baby cried after birth - Yes/No
5) Weight of baby-
6) APGAR Score-

History of previous abortions:

a) Stillborn/death after birth-

b) Type of abortion-

History of any disease during pregnancy: PID/malaria/dengue

History of any malignancy:

History of postural hypotension:

Any trauma during delivery:

Menstrual History:
Age of Menarche:

Regularity of Cycle:

Duration of Cycle:

Duration of Period:

Flow:

Type of pad used:

No. of Pads Per Day:

Past History:
1. Medical History:
1) Hypertension – Yes/No
2) Epilepsy – Yes/No
3) Diabetes – Yes/No
4) Asthma – Yes/No
5) Tuberculosis – Yes/No
6) Covid 19 – Yes/No
7) Jaundice – Yes/No
2. Surgical History: Present/Absent
If present then which and when? -

Personal History:
1. Sleep: Normal/Disturbed/Decreased/Increased
1) If a disturbing reason? –
2) Any medications –
2. Appetite: Normal/Decreased/Increased
1) Type of Food – Veg/Non-veg/Mixed
2) Meals per day –
 3) Duration between two meals –
4) Any medications –
3. Bowel: Continent/Incontinent/Constipation
1) Frequency –
2) Any difficulty in process –
3) H/o constipation –
4) Any medications –
4. Bladder: Continent/Incontinent
1) Frequency –
2) H/o incontinence –
a) Dribbling of urine during coughing or other activities
b) Feeling of something descending per vagina
5. Addiction: Yes/No

Family History:
1) Congenital Disease: Yes/No
2) Any Hereditary Disease: Yes/No
3) Diabetes: Yes/No
4) Heart Disease: Yes/No
5) Any Mental Retardation: Yes/No
6) Hypertension or PIH: Yes/No
7) Multiple Pregnancy: Yes/No If yes in whom? –

Drug history:
1) Any drugs are taken during pregnancy -

2) Allergic to any drug -

3) History of any oral contraceptives -

4) Any Rh compatibility injections are taken during previous pregnancy –

 Present Drug History:

General Examination:
Higher Center Examination:

i. Consciousnesses: Conscious/Not
ii. Orientation: Well oriented/Not
iii. Memory: Immediate/Short-term/Long-term
iv. Attention: Attentive/Not attentive
v. Speech:
vi. Hearing:

General condition of patient:

Weight:

Hight:

BMI: Built: Ectomorph/Mesomorph/Endomorph

Cardinal Signs:

i. Pallor: Present/Absent
ii. Icterus: Present/Absent
iii. Cyanosis: Present/Absent
iv. Clubbing: Present/Absent
v. Oedema: Present/Absent If present site, extent & type?
vi. Lymphadenopathy: Present/Absent If present site? –

Vitals:

i. B.P =
ii. Pulse Rate =
iii. Respiratory Rate =
iv. Temperature =
v. SPO2 =

Abdominal Examination:
On Inspection/Observation –

1. Shape of the abdomen:

2. Umbilicus: Everted/Inverted
3. Linea nigra:
 4. Striae gravidarum (with site):
5. Striae Albicans (with site):
6. Bandage: Present/Absent If present site? –

On Palpation –

1. Local temperature –
2. Tenderness –
3. Abdominal circumference –
4. Bandage Extent –
a. 1st bandage length
b. 1st bandage width
c. 2nd bandage length
d. 2nd bandage width
5. Diastasis Recti Assessment – Present/Absent
If present then how much? –

Breast Examination:
On Inspection/Observation:

1. Size of the breast: Symmetrical/Unsymmetrical

2. Colour of the nipple:
3. Stretch marks: Present/Absent
4. Dilated veins: Present/Absent
5. Discharge: Present/Absent

On Palpation:

1. Local temperature:
2. Tenderness: {Breast Engorgement Scale}
Pelvic Floor Muscle (PFM) Assessment:
GRADES DESCRIPTION

GRADE 1- no contraction Contraction held less than 1sec

GRADE 2- weak Contraction held for 1-3 secs

GRADE 3- moderate Contraction held for 4-6secs, repeat 3times

GRADE 4- strong Contraction held for 7-9 secs, repeat 3times

GRADE 5- very strong Rapid contraction for 7-9secs; repeat 4 times.

 PERFECT scoring-

i. Power -

ii. Endurance -

iii. Repetitions -

iv. Fast contractions -

v. Each contraction time -

Lochia Assessment:
1. Colour:
2. Flow:
3. Odor:
4. Clots:
5. Duration:
6. No. of pads per day:
Posture Assessment:
Anterior view:

1. Head –
2. Shoulders –
3. Elbow –
4. Pelvis (ASIS) –
5. Hip Joint –
6. Knee Joint –
7. Feet –
8. Toes –

Posterior View:

1. Head –
2. Cervical Spine –
3. Shoulders –
4. Scapulae –
5. Thoracic & Lumbar Spine –
6. Pelvis (PSIS) –
7. Hip Joint –
8. Knee Joint –
9. Ankle Joint –

Lateral View:

Sr. RIGHT SIDE LEFT SIDE

No.
1. Head
2. Cervical Spine
3. Shoulder
4. Thoracic Spine
5. Lumbar Spine
6. Pelvis
7. Hip Joint
8. Knee Joint
9. Ankle Joint
Gait Assessment:

1. Type of Gait:
2. Phases of gait:
3. Step length:
a) Right =
b) Left =
4. Stride Length -
5. Step Width -
6. Cadence-

Cardio Assessment:

1. Apex beat –
2. S1 and S2 Sound –
3. Any adventitious sound –

Respiratory Assessment:

1. Shape of chest –
2. Chest symmetry –
3. Breathing Pattern –
4. Type of breathing –
5. Accessory muscle use? – Present/Absent
6. Air entry –
7. Any adventitious sounds? – Present/Absent
Musculoskeletal Assessment:

 ROM (Range of Motion):

1. UPPER LIMB
Sr. UPPER LIMB ACTIONS RIGHT LEFT
No. JOINTS

1. Shoulder Flexion

Extension

Adduction

Abduction

Medial Rotation

Lateral Rotation

2. Elbow Flexion

Extension

3. Wrist Flexion

Extension

Radial Deviation

Ulnar Deviation

2. LOWER LIMB
Sr. LOWER ACTION RIGHT LEFT
No. LIMB
JOINTS

1. Hip Flexion

Extension

Adduction

Abduction
 Medial Rotation

Lateral Rotation

2. Knee Flexion

Extension

3. Ankle Dorsiflexion

Plantarflexion

3. TRUNK
Sr. No. TRUNK ACTION ROM

THOCIC SPINE THORACO-

LUMBAR
1. Flexion
2. Extension
3. Right side flexion
4. Left side flexion
5. Right side rotation
6. Left side rotation

 MMT (Manual Muscle Testing):

1. UPPER LIMB
Sr. UPPER MUSCLES RIGHT LEFT
No. LIMB
JOINTS
1. Shoulder Flexors
Extensors
Abductors
Adductors
Medial Rotators
Lateral Rotators
2. Elbow Flexors
Extensors
3. Wrist Flexors
Extensors
Radial Deviators
Ulnar Deviators

2. LOWER LIMB
Sr. LOWER MUSCLES RIGHT LEFT
No. LIMB
JOINTS
1. Hip Flexors
Extensors
Adductors
Abductors
Medial Rotators
Lateral Rotators
2. Knee Flexors
Extensors
3. Ankle Dorsiflexors
Plantar flexors

3. TRUNK
Sr. TRUNK MUSCLES ROM
No. THOCIC SPINE THORACO-LUMBAR
1. Flexors
2. Extensors
3. Right side flexors
4. Left side flexors
 5. Right side rotators
6. Left side rotators

Investigations:
1. CBC
2. LFT
3. KFT
4. HIV
5. USG
6. Blood sugar level

ICF
 HEALTH CONDITION
 STRUCTURAL IMPAIRMENT
 FUNCTIONAL IMPAIRMENT
 ACTIVITY LIMITATIONS
1) Domestic Life -
2) Self-care –
3) Mobility –
 PARTICIPATION RESTRICTION
1) Major Life Area –
2) Social Life Area –
3) Interpersonal Relationship –
 CONTEXTUAL FACTORS

1] Environmental Factors

PROMOTORS BARRIERS

2] Personal Factors

PROMOTORS BARRIERS