PNC ASSESSMENT

PRESENTED BY :- 
DURRATUSSHARAF GHADIALI – 16 
SEJAL GHARAT – 17
FORAM GHODERAO – 18
SAHIL LIKHITE – 46
SNEHA LUND – 47
SUMMAYYA MAHALDAR - 48
DEMOGRAPHIC DETAILS 

► NAME – MAYURI PATIL 

► AGE – 25 
► ADDRESS – KOLHAPUR, SINCE 3 MONTHS RESIDING IN PANVEL, WESTERN SANITATION INSIDE THE
HOUSE
► EDUCATION – GRADUATE  
► OCCUPATION – ACCOUNTANT, LEFT JOB SINCE START OF PREGNANCY
► MARITAL STATUS – MARRIED 
► DURATION OF MARRIAGE – 1 YEAR 
► DATE & TIME OF DELIVERY – 17/08/22 AT 10:00 AM
► DATE OF EVALUATION - 18/08/22
► CHIEF COMPLAINT – PAIN AT SUTURE SITE NEAR PERINEUM SINCE 1 DAY
TENDERNESS AT BILATERAL BREAST – LOWER QUADRANTS SINCE 1 DAY.
PAIN HX

► ONSET – SUDDEN
► PAIN LEVEL –
▪ CURRENT PAIN – 4/10
▪ WORSE PAIN – 6/10
▪ BEST PAIN – 3/10
► PAIN TYPE – DULL ACHING
► PAIN LOCATION – SUTURE SITE AT PERINEUM
► RELIEVING FACTORS – REST
► AGGRAVTING FACTORS – ANY TYPE MOVEMENT
► FREQUENCY – INTERMITTENT
► DIURNAL VARIATION – ABSENT
MENSTRUAL HX 

► AGE OF MENARCHE – 12 YEARS 

► MENSTRUAL CYCLE – REGULAR 

► FLOW – FIRST 3 DAYS MODERATE 

► DYSMENORRHEA – FIRST 3 DAYS 

► DURATION OF CYCLE – 28 DAYS FOR 5 DAYS

► NUMBER OF PADS PER DAY – 4/DAY

OBSTETRIC HX 

► TYPE OF MARRIAGE – NON CONSANGUINEOUS 

► TYPE OF CONCEPTION – NATURAL, UNPLANNED
► AGE OF MOTHER AT TIME OF FIRST CHILD – 25 YEARS 
► LMP – 10/11/21
► EDD – 17/08/22
► GPLAD – G1P1L1A0D0
► WEIGHT OF MOTHER - 
▪ BEFORE PREGNANCY - 39 KGS 
▪ AFTER PREGNANCY - 49 KGS
▪ WEIGHT GAIN – 10 KGS WEIGHT GAIN FROM CONCEPTION TILL THE 9TH MONTH
ANTENATAL HX 

SECOND
FIRST TRIMESTER  TRIMESTER  THIRD TRIMESTER 
• INVESTIGATIONS – 15/02/22 • INVESTIGATIONS – 05/04/22 • INVESTIGATIONS – 14/07/22
• USG & CBC  • USG & CBC  • USG & CBC 
• FOETAL MOVEMENTS WELL • FOETAL MOVEMENTS WELL • FOETAL MOVEMENTS
APPRECIATED  APPRECIATED  WELL APPRECIATED 
• PLACENTA – FUNDO • PLACENTA – FUNDO • PLACENTA – FUNDO POSTERIOR
POSTERIOR LOW LYING POSTERIOR NOT LOW LYING NOT LOW LYING
• CARDIAC ACTIVITY PRESENT • CARDIAC ACTIVITY PRESENT  • CARDIAC ACTIVITY PRESENT 

• ADVICE – PATIENT WAS • ADVICE – PATIENT WAS • COMPLAINTS – PATIENT

ADVICED FOR BED REST FOR 2 PRESCRIBED IRON AND STARTED EXPERIENCING LOW
MONTHS. CALCIUM SUPPLEMENTS   BACK ACHE.
 LABOUR HX 

STAGE I STAGE II STAGE III

• PATIENT WAS ADMITTED IN • PATIENT WAS MOVED INTO THE • PLACENTA DELIVERED
DELIVERY ROOM AFTER ADEQUATE
MGM HOSPITAL, KALAMBOLI SPONTANEOUSLY WITH INTACT
DILATION OF CERVIX AND WAS IN A
16/08/22 AT 4PM DUE TO PAIN IN LITHOTOMY POSITION . MEMBRANE. 
THE ABDOMEN SINCE
• SHE BEGAN TO PUSH BUT DUE TO
MORNING. EXHAUSTION SHE WAS ASSISTED BY
THE NURSES. 
• SHE WAS ADMINISTERED WITH
EPIDURAL AT THE TIME OF • EPISIOTOMY (MEDIO-LATERAL)
ADMISSION. PERFORMED AT PEAK CONTRACTIONS
AND ASSISTED BY FORCEPS
• STAGE 1 LASTED FOR (INSTRUMENTS)
17 HOURS. • BABY DELIVERED IN VERTEX POSITION
AND IMMEDIATE BIRTH CRY PRESENT.

•  STAGE 2 LASTED FOR 1 HOUR.

NEONATAL HX 

► WEIGHT OF INFANT – 2.64KGS

► GENDER – FEMALE 
► IMMEDIATE BIRTH CRY – PRESENT 
► APGAR SCORE – 8/10 
► NEONATAL REFLEXES – PRESENT 
► IMMUNISATION AT BIRTH – BCG, OPV-0, HEPATITIS B1
► HEAD CIRCUMFERENCE - 32 cms
IMMUNISATION SCHEDULE
IMMUNISATION SCHEDULE
PERSONAL HX 

► SLEEP – NORMAL 
► B/B - NORMAL 
► DIET – MIXED
► APPETITE – NORMAL
► ADDICTIONS – DENIED 
MEDICAL HX & SURGICAL HX  

► MEDICAL HX – NO H/O HTN, DM, THYROID.

► SURGICAL HX - NONE 
DRUG HX

► CALCIUM AND IRON + FOLIC ACID SUPPLEMENTS

SOCIO ECONOMIC STATUS 

► NO. OF MEMBERS – 4
► EARNING MEMBERS – 2 
► ANNUAL INCOME > 2.5L
► KUPPUSWAMY SCORE – 22 
► ACC. TO MODIFIED KUPPUSWAMY SCALE – UPPER MIDDLE CLASS.
ASSESSMENT – ON OBSERVATION 

► BUILT – MESOMORPHIC 
► ATTITUDE OF LIMBS – LONG SITTING WITH BACK WELL RESTED 
► PALLOR – ABSENT 
► ICTERUS – ABSENT 
► CYNOSIS – ABSENT 
► LYMPHOEDEMA – ABSENT 
► EDEMA – ABSENT 
► HEIGHT – 153 cms
► WEIGHT – 49 kgs
► BMI – UNDERWEIGHT BY 2 kgs
 ON OBSERVATION CONT.

► POSTURE - 
▪ ANTERIOR VIEW – LEFT SHOULDER ELEVATED 
▪ POSTERIOR VIEW -  LEFT SHOULDER ELEVATED
▪ LATERAL VIEW – ROUNDED SHOULDERS, FORWARD HEAD POSTURE.
► GAIT –
▪ PATIENT AMBULATORY INDEPENDANTLY. 
▪ WADDLING GAIT PRESENT .
▪ STEP LENGTH DECREASED. 
▪ CADENCE INCREASED. 
▪  ALL PHASES OF GAIT PRESENT.
► LINEA NIGRA – PRESENT 
► STRIAE GRAVIDARUM – ABSENT
Posture

Anterior View Posterior View Lateral

GAIT

https://drive.google.com/file/d/1IdFUYwCNPfMuiJM624i6qtvXxaBfOAWc/view?usp=drivesdk
ASSESSMENT – ON EXAMINATION

► VITALS 
▪ BP – 120/80mmHg
▪ RR – 12 breaths per minute 
▪ PR – 80bpm
▪ TEMPERATURE – AFEBRILE 
► SCAR – PRESENT
► SUTURE – PRESENT 4 cms, 5 stitches
► REEDA - 1
► LINEA NIGRA – 24 cms 
► HYPER LAXITY - 3/9 (BEIGHTON
HYPERLAXITY SCALE)
HYPERLAXITY BY BEIGHTON SCALE
BREAST EXAMINATION 

► HYPER PIGMENTATION – PRESENT 

► SYMMETRY – ASYMMETRIC, LEFT ENLARGED THAN
RIGHT
► LUMPS / NODULES – ABSENT 
► NIPPLES – NORMAL – CENTRED & RETRACTED
► BREAST ENGORGEMENT SCALE – 4 (FIRM BEGINNING
TENDERNESS)
► TENDERNESS –
▪ 1ST DAY POST OP – PRESENT (B/L LOWER MEDIAL &
LATERAL LOWER QUADRANTS)
▪ 2ND DAY POST OP – PRESENT (RIGHT UPPER MEDIAL &
LATERAL QUADRANTS) 
► DISCHARGE – ABSENT 
 CORE STRENGTH & PFM STRENGTH 

► CORE MUSCLE ASSESSMENT 

▪ STRENGTH – WEAK 
▪ SPHYGMOMANOMETER TEST  -6mmHg for 15 secs hold 
▪ PATIENT COULD PERFORM FOR 1 TRIAL AND DENIED FOR THE REMAINING TWO TRIALS.
► PELVIC FLOOR MUSCLES STRENGTH 
▪ POWER (ACC TO MODIFIED OXFORD SCALE) - 2 (WEAK)
▪ ENDURANCE(SECS) - 14 
▪ REPETITIONS – 3 
▪ FAST CONTRACTIONS - 2
▪ EACH 
▪ CONTRACTION 
▪ TIMED 
▪ INTERPRETATION – OUR ASSESSMENT DESCRIBES THAT THE PATIENT WITH WEAK CONTRACTIONS HELD FOR 14 SECS
AND REPEATED 3X FOLLOWED BY FAST CONTRACTIONS.
PERINEUM EXAMINATION

► ODOUR – ABSENT 
► LOCHIA – PRESENT WITH SCANTY
FLOW
► COLOUR OF LOCHIA – RED (LOCHIA
RUBRA) 
► ODOUR – ABSENT 
► SKIN – NORMAL 
ICF - HEALTH STATUS

HEALTH STATUS —
MRS. MAYURI PATIL, 25 YEAR OLD FEMALE DELIVERED A BABY GIRL
ON 17/08/22 AND COMPLAINS OF PERINEUM PAIN SINCE 1 DAY AND
TENDERNESS AT THE BREASTS BILATERALLY SINCE 1 DAY

COMORBIDITIES - NONE
 ICF – FUNCTIONING AND DISABILITY 

BODY
INTAC
STRUC IMPAIRED CLINICAL REASONING  QUALIFIER 
T
T-URE 
1. Structures Kidneys, urinary Uterus, vagina, 1. Due to physiological changes post-delivery, MODERATE
related to bladder perineum and involution of uterus.
genitourinary perineum muscles
system 2. Shredding of the uterus due to the necrosis
& sloughing of superficial and basal layer of
endometrium.

3. Episiotomy to accelerate labour and avoid

excessive stretching of surrounding tissues.
FUNCTIONING AND DISABILITY 

BODY INTACT IMPAIRED CLINICAL REASONING  QUALIFIER

STRUCTURE
 
STRUCTURES MUSCLE OF UL & Pelvic Floor 1. Hormonal changes during MODERATE
REALTED TO LL Muscles.  pregnancy, leads to progressive
MOVEMENT increase in volume of uterus
leads to major load on perineal
structures.

2. Stretching of pelvic floor

muscles during delivery

3. Reduced strength of PFM due

to episiotomy.
FUNCTIONING AND DISABILITY

BODY INTACT IMPAIRED CLINICAL REASONING  QUALIFIE

STRUCTURE  R

Skin and related Pigmentation - Stimulation of melanin

structures aerola, linea nigra production by ant. Pituitary
resulting in darkening of skin
around aerola & linea nigra
Breasts – lt breast Increased milk secretion from
engorgement  2-4th day leading to lymphatic
and vascular congestion results
Tenderness – rt in interstitial edema and causes
upper lateral and swelling and tenderness in the
medial quadrant breast
FUNCTIONING AND DISABILTY
BODY INTACT IMAPAIRED CLINICAL QUALIFIER
STRUCTURE REASONING
Structures related Core muscles During pregnancy, MODERATE
to the growing uterus
neuromusculoskel stretches the
eton system muscles in the
abdomen.
This leads to the
two large parallel
bands of the
muscles that meet
in the middle to be
separated by an
abnormal distance
leading to
diastasis recti.
FUNCTIONING AND DISABILITY 
BODY INTACT IMPAIRED  CLINICAL REASONING  QUALIFIER
FUNCTION   
Pain and Sensations  Pain - Perineum  Due to episiotomy, caused by incision Moderate
sensory of superficial transverse perineal
functions  muscle and bulbar spongy muscle.

This leads to sensitization of free

nerve endings of C fibers & A delta
fibers. 

These nociceptors when expsoed to

any stimuli causes pain due to tissue
damage and inflammation.
Gait – waddling Bilateral weakness in gluteus medius Moderate
gait muscles.
 FUNCTIONING AND DISABILTY

BODY INTACT IMAPAIRED CLINICAL QUALIFIER

FUNCTION REASONING

FUNCTIONS CORE Due to diastasis Moderate

RELATED TO STRENGTH recti the entire
MOVEMENT abdominal core
muscles will be
weakened with
very little
mechanical
control.
ACTIVITIES AND LIMITATION
DOMAIN : ACTIVITY / LIMITATION / CAPACITY PERFORMANC
ACTIVITIES / PARTICIPATIO RESTRICTION E
PARTICIPATIO N S
N
D4 : MOBILITY WALKING PATIENT PATIENT PATIENT
CANNOT WALK CANNOT WALK REQUIRES
FOR 10 MINS DUE TO MINIMAL
DUE TO PAIN WEAKNESS IN ASSISTANCE
AT THE THE PELVIC WHILE
PERINEUM MUSCLES WALKING
D5 ; SELF TOILETING PATIENT IS PATIENT PATIENT
CARE UNABLE TO
PERFORM
TOLIETING
ACTIVITIES
NORMALLY
DUE TO PAIN
AT PERINEUM.
CONTEXTUAL FACTORS

EVIRONMENTAL FACILITATOR BARRIER

FACTORS
SUPPORT AND PATIENT HAS
REALTIONSHIP SUPPORTIVE FAMILY
NATURAL PATIENT RESIDES NEAR
ENVIRONMENT AND THE HOSPITAL
MAN MADE CHANGES PATIENT HAS WESTERN
TO THE ENVIRONMENT TOILET INSIDE THE
HOUSE
ATTITUDE FAIR AND COOPERATIVE
CONTEXTUAL FACTORS

PERSONAL FACTORS FACILITATOR BARRIER

AGE / GENDER PATIENT 25 YEARS OLD
FEMALE
COPING STYLES PATIENT IS
COOPERATIVE AND
UNDERSTAND THE
EXERCISES PROPERLY
EDUCUCATION PATIENT IS GRADUATE
AND UNDERSTANDS
IMPORTANCE OF
PHYSIOTHERAPY
PROFESSION PATIENT IS NOT
WORKING DUE TO POST
LABOUR PAIN.