POSTNATAL ASSESSMENT
History taking
Biographic data:
Name; date:
Age: D.O.A:
Sex: hospital:
Marital status: IP .No:
Married……… Unmarried……… unit:
Widowed……. Divorced……….. ward:
Religion: bed no:
Nationality: diagnosis:
Education: date of delivery:
Occupation: type of delivery:
Monthly income: normal: episotomy:
Address: LSCS: forceps:
Phone no:
2. Chief complaints:
1.
2.
3.
Present obstetrical history:
Gravida Parity Period of Nature of delivery Method of Out- come of Remarks
gestation delivery pregnancy
Full term preterm
1.Prolonged delivery: yes……no….
2.complicated delivey: yes…..no….
3.pueperium:
4.postpartum haemorhage : mild…….moderate…… severe……
6.if yes: specify: PIH……… eclampsia…….anemia….. renal failure…….
Gestational diabetes mellitus…..
7.feeding method: breast…….. bottle…..
8. family planning:…. Yes……. No……….
If yes specify temporary: yes……no………specify
9.Any other: yes……. No……..
If yes specify:
4.Past obstetrical history:
……………………………………………………………………………………………
……………………………………………………………………………………………
Any congenitial deformities no….to baby ……. Yes…… no
Any others yes……no…..if yes specify……….
5. Medical history:
1. Any childhood illness yes…..no……
2.If yes specify T.B …….convulsion….. measles…..mumps……typhoid…..rheumatic
fever……
3.Heart disease yes…….no…..if yes specify
4.Breast cancer: yes…..no……if yes specify…….
5.Lung disease : yes…..no……if yes specify……
6. Muscles or bone problem: yes…..no…..if yes specify…..
7.thyroid disease: yes….no…..if yes specify……
8.G.I problems:yes….no…..if yes specify….
9.Urinary problems: yes….no…..if yes specify…….
10. Pelvic inflammatory disease: yes…..no….if yes specify……..
11. S.T.D disease: yes….no…..if yes specify…….
12. Essential hypertension: yes….no……if yes specify…….
13.Mental illness: yes……no…….if yes specify…….
14.Tumors of any kind : yes…. No….. if yes specify……
15. History of any kind: yes…no….if yes specify…….
16.History of any blood transfusion: yes……no……if yes specify…….
17. History of traumatic injuries: yes……no…….if yes specify…….
18. Any other: yes….no……if yes specify…….
6. History of previous hospitalization:
7. Past surgical history:
History of surgeries: yes…..no,….if yes specify
Surgery …… cause…..outcome……
8. Family History:
Consanguineous marriage yes…no….
Type of family joint….nuclear….
Position in the family……
History of family illness: yes…. No… if yes… diabetes….Hypertension
Tuberculosis….. Heart diseases……epilepsy…..asthma…. anyother..….
Family tree:
Male
Female
Dietary history : Vegetarian…….Non vegetarian
Types of food intake: rice…. Wheat ….. jowar…..
No. of times food intake: ……appetite…..
History of any allergies: yes….. no…… if yes specify….
Food….. drugs……cosmetics……pet animals
Others…..reaction……treatment taken…
Menstrual history:
Age at menarche:
Cycle: Regular……. Irregular
Duration…..1-3days….3-5days…..more than 7days
Flow: Moderate….. severe….
Premenstrual symptoms: Yes……no…..
If yes: 1…..2…..3…..
9. Socio economic history:
Housing: kaccha…..Pucca….
Lighting :….. adequate…. Inadequate…..
Drainage: Closed…..Open’…..
Living locatlity: Urban… Urban slum…. Rural…
Occupation……
Type of work ; heavy….. moderate….. sedentary…..
Watersupply: Well….. Borewell…..Publictap
10. Personal history:
Activities of daily living:
Dependent….Independent…..Partial depedent……
Bathing: yes….no….if no. of times perday
Brushing: no. oftimes…… types of dentrifice……
Frequency……. Color…..consistency……
Regular……..irregular……
Sleep and rest: Usual bed time……. Time of awakening…..
Hours of slee[…… sleep disturbances……
Nature of sleep…… sound….. disturbed…..insomnia….
Personal habits:
Smoking: yes……. No…… if yes since…. No. of packs perday……frequency…
Occasionally……sometimes….very often……
Tobacco chewing: yes….no…. if yes since… no. ofpacks per day…….
Frequency….. occasionally……..sometimes…..very often….
Drug abuse: yes…. No…..if yes since….. no of packs perday……. Frequency……
Occasionally…….sometimes….very often…name of the drug..
Physical examination:
General appearance: healthy….ill/ sick
Orientation to time…..place….person…..
Height…….Weight…..
Vital signs: Temperature….. pluse…. Respiration…..B.P…..
Built…..moderate ……obese….emaciated…..
Posture…..Symmetric,……a symmetric……
Level of consciousness:…. Conscious…. Drowsy….semiconscious….
Unconscious……
Mood pleasant…..cooperative……uncooperative…..depressed….
Fearful…..anxious….
State of comfort: alert…distressd….apathy….lethargy….
Personal hygiene: appropriate…..in appropriate:
Appropriate eye to eye contact: yes….no….
Inspection:
Hair: thick….scanty…alopecia….
Skull: summetry……asymmetry…
Scalp: normal….pallor….flushed,…..cyanosed……symmetrical…
Eyes: Symmetrical…..asymmetrical,….puffy,,…..periorbital swelling….
Eyebrows: normal… equal alignment….unequal…
Conjuctiva noemal….red…pale….purulent…
Pupil reaction to light……
Lens: normal….opaque….
Alteration in vision: yes…no…
Ears; symmetrical…..asymmetrical…
Discharge: yes…no….
If yes specify right ear….left ear…..both ears….
Nose: normal….septal deviation…..
Mouth: normal….cleft lip…..
Gums: pink….. bleeding……swollen….
Lips: pink….pale….
Neck: lymphnodes: normal….enlarge…
Thyroid gland: normal……enlarge…..
Jugular venous distension: present…..absent…..
Chest:
Symmetrical….. asymmetrical……
Shape: normal…. Barrel chest…..pegion chest…..funnel chest…
Kyphoscoliosis:
Breast enlargement: yes….no…..
Nipples: normal…. Inverted ….retracted….cracked….
Soreness of nipples: yes….no…..
Any unusual discharge: yes….no….
Breastfeeding: when started….colostrum….frequency…..duration…
Breast feeding techniques: following…. Not following….
Precussion dullness…… Resonance…. Hyper resonance…
Auscultation ling normalbreath sounds,….creptius….wheeze….
Heart S1……S2….murmurs…..
Abdomen soft…. Hard…..
Inspection: shape….contour…..
Scars: yes… no.. if yes specify…….
Incision wound: Yes……no……
Type of incision: vertical…. Trasverse…..
Sutures: intact…not intact…..
Wound dehiscence…..yes….no…….
Any discharge: yes…..no…… if yescolor…..consistencies,…..
Height of uterus:
Auscultation: bowel sounds: regular……..irregular…. abscent….
Palpation: involution of uterus….
Tenderness: yes… no…masses yes…. No…. mobile…. Immobile….size…..
Location……
Precussion: dullness ……tympany……
Perineum: Intact….tear…..wound…..
Genetatalia: vulva……normal…..swelling….tender…….
Lochia rubra…….
Lochia serosa……
Lochia alba……
Frequency of diaper change….perday….
Episiotomy: yes….no….type…..
Healthy; signs of infection: yes…. No…. if any specify color,…….. amount…
consistency………
Anal sphincter tone good….flaccid….anal fissures…..
Upper extremities: symmetrical……asymmetrical…..
Deformities…. Contractures……
OEdema: present…. Absent…. If present pitting… nonpitting….
Nails.: normal……spoon shaped….cyanosis….pallor…..brittle….
capillary refile; < 3sec….>3sec…..
Lower extremities:
Semmetrical…..asymmetrical…deformities…cantractions….
Oedema: present…..absent…. if present pitting… nonpitting…
Viricose veins: yes…. No…..
Human’s sign:…… patellar reflexes….
Investigations:
