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PNC Case

The document is a postnatal case report template that collects comprehensive information about the mother and baby, including personal details, antenatal and postnatal history, examination findings, and provisional diagnosis. It outlines the necessary investigations and treatments advised at discharge, along with contraception recommendations. The form is intended for use by healthcare professionals to ensure thorough documentation of postnatal care.

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huzera khan
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© © All Rights Reserved
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172 views3 pages

PNC Case

The document is a postnatal case report template that collects comprehensive information about the mother and baby, including personal details, antenatal and postnatal history, examination findings, and provisional diagnosis. It outlines the necessary investigations and treatments advised at discharge, along with contraception recommendations. The form is intended for use by healthcare professionals to ensure thorough documentation of postnatal care.

Uploaded by

huzera khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Postnatal Caseitions)

Narne: Age:
Address:
occl!pation:
socioeconomic status: Religion: Caste:
education:
sooked / registered (number of antenatal visits in pregnancy):
Date and Time of Delivery :
Gestational Age at Delivery :

lnteranatal History
Relevant complaints at time of admission:

Examination findings at time of admission:

Duration of labour:
PPH: Yes/ No
Any abnormal findings:
Type of delivery:
If caesarean or instrumental delivery: Indication
Condition of baby at birth:
Time of birth, sex of baby, birth weight:
Baby with mother /in NICU:

Postnatal history:
Lochia:
Pain:
Bowel/bladder:
Breast feeding or any problem:

Antenatal History:
Obstetric history :
Past ·medical history :
Family history :
Diet history :
Personal history :
General examination :
. Built: . Height:
. .,. · . .
Weight: Nourishment:
General condition :
Temperature :
Pulse: Respiration :
BP :
.•.
Pallor, tcterus, Cyanosis; Glossitis, Angula
r Stomatitis, JVP, Lymphadenopathy, Clubbing
, Gaue
Breasts:
Systemic examination :
CVS
RS
I CNS
·. .

Abdominal Examination :

Inspection :
Pal pat ion :
Fundal height :
Involution of uterus :
Bowel° ·s~u~ds· in case of caeser :
Abdominal wound / Perineum :
Bleeding PV / Loc hia :
Urine Output :

Provisional Diagnosis :

Investigations:
Routine:
h Typing Hb
H\V
VDRL
ectr0Phoresis
SerumTSH
Urine Culture
Sensitivity
~ -t1gat1
ons:

~ advised/given
1 to

re

Treatment Advis
ed a t Discha
rg e:

Contraception A
dvised:

Signature of T
eacher:
Oate:

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