1 - Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF DISSERTATION

TOPIC

“THE PREVALENCE AND CLINICAL SIGNIFICANCE OF FEBRILE MORBIDITY IN POSTPARTUM PERIOD”

DR.RUMA DUTTA

POSTGRADUATE RESIDENT,

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY,

KVG MEDICAL COLLEGE AND HOSPITAL

SULLIA, KARNATAKA.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

ANNEXURE- II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

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|1 |NAME OF THE CANDIDATE AND ADDRESS |DR. RUMA DUTTA |

| |(IN BLOCK LETTERS) |POSTGRADUATE RESIDENT, |

| | |DEPT. OF OBSTETRICS AND |

| | |GYNAECOLOGY, |

| | |KVG MEDICAL COLLEGE AND HOSPITAL |

| | |SULLIA. |

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|2 |NAME OF THE INSTITUTION |KVG MEDICAL COLLEGE AND HOSPITAL |

| | |KURUNJIBAG, SULLIA |

| | |DAKSHINA KANNADA-574327 |

| | |KARNATAKA. |

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|3 |COURSE OF STUDY AND SUBJECT |M.S OBSTETRICS AND GYNAECOLOGY |

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|4 |DATE OF ADMISSION TO COURSE |31/7/2013 |

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|5 |TITLE OF THE TOPIC |THE PREVALENCE AND CLINICAL SIGNIFICANCE OF FEBRILE MORBIDITY IN POSTPARTUM PERIOD. |

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| |6. BRIEF RESUME OF THE INTENDED WORK: |

| |6.1 Need for the study: |

| |Puerperal fever (from Latin, ‘puer’ means child) also called child bed fever is contracted by women during or shortly after child |

| |birth, miscarriage or abortion leading to septicaemia and death. Along with pre-eclampsia and obstetrical haemorrhage, it has formed|

| |the lethal triad of causes of maternal death for many decades. It is the leading cause |

| |of preventable maternal morbidity and mortality not only in developing countries but developed countries as well.1 |

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| |Firm estimates of the incidence of postpartum infection are not readily available. Many studies have reported the |

| |incidence of “standard puerperal morbidity”, which was defined by US joint committee on maternal welfare as “a temperature of |

| |100.4º F , the temperature to occur in any two of the first 10 days postpartum ,exclusive of the first 24 hours, and to be taken by |

| |mouth by a standard technique at least four times daily”.2 |

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| |The global incidence of puerperal sepsis is estimated to be 4.4% of live births. The Scottish Confidential Audit of |

| |Severe Maternal Morbidity (SCASMM) showed a 0.11 per 1000 births rate of septicaemic shock in the triennium 2006-2008. The|

| |2011 NICE Guideline on Caesarean Section (CS) recommends routine antibiotic prophylaxis to reduce the incidence of |

| |infections such as endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a caesarean |

| |section .3 |

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| |In India, maternal deaths from puerperal sepsis account for approximately 15% of all maternal deaths. A sixteen year study from |

| |northern India found that sepsis was responsible for over 35% of maternal deaths and a study in southern India revealed that sepsis was|

| |a leading cause of maternal death responsible for 41.9% of deaths. Demographic and health survey shows that the majority of women do |

| |not receive a postnatal check-up and 14% of women who had a birth in the last 5 years reported very high fever in the postpartum |

| |period.4 |

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| |6.2 Review of literature : |

| |The International Classification of Diseases (ICD-10) defines postpartum (puerperal) sepsis as a temperature rise above 38.0 °C |

| |(100.4°F) maintained over 24 hours or recurring during the period from the end of the first to the end of the tenth day after |

| |childbirth or abortion.5 |

| |Most persistent fever after childbirth is due to genital tract infection .Filker and Moniff (1979) reported that only 20% of women |

| |febrile within 24hrs after giving vaginal birth were subsequently diagnosed with pelvic infection caused by group A streptococcus . |

| |This was in contrast to 70% of those undergoing caesarean section. Other common causes of puerperal fever are breast engorgement and |

| |pyelonephritis occasionally, respiratory complications after caesarean delivery About 15% of women who do not breast fed develop |

| |postpartum fever from breast engorgement.6 |

| |Acute pyelonephritis has a variable clinical picture, and postpartum, the first sign of renal infection may be fever, followed by |

| |costovertebral angle tenderness, nausea and vomiting. Atelectasis is caused by hypoventilation and is best prevented by coughing and |

| |deep breathing on a fixed schedule following surgery. Fever associated with atelectasis is thought to follow infection. by normal flora|

| |that proliferate distal to obstructing mucous plugs ,minor temperature elevations in puerperium may also be caused by superficial or |

| |deep venous thrombosis of the legs .6 |

| |Postpartum infections occur in about 1 to 8% of vaginal deliveries and it is 5 to 10 times higher following caesarean section. Some |

| |studies tells puerperal infections affects 2 to 10% of patients. Initial infection is confined to the endometrium and myometrium,also |

| |known as endomyometritis. If not promptly and adequately treated,it may progress directly or through the lymphatics to cause serious |

| |life threatening pathology like parametritis, salpingo-oophoritis, septic pelvic thrombophlebitis, pelvic abscess, intra-abdominal or |

| |metastatic abscesses, even generalized peritonitis, bacteraemia, septicaemia, and endotoxic shock and rarely death.7 |

| |From epidemiology of and surveillance for postpartum infections by Deborah S.Yokoe post-partum infection rate was 6.0%, with rates of |

| |7.4% following caesarean section and 5.5% following vaginal delivery. Mastitis and urinary tract infections accounted for >80% of these|

| |infections.8 |

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| |Shamsad et al. conducted an observational study in Ayub Teaching Hospital, Pakistan, over a period of three years 1st January 2005 to |

| |31st December 2007. All patients admitted with diagnosis of puerperal sepsis secondary to genital tract infection were evaluated. It |

| |was 1.7% of all obstetrical admissions and 34.4% of postnatal complications. It was seen common among young patient of 15-25 years age,|

| |61(66.3%),of lower parity, 58(63.00%),low socioeconomic status, 60(65.20%), uneducated patients, 72(78.20%),home deliveries |

| |68(73.90%),prolonged labour,54(58.60%), prolonged rupture of the membrane from 48-72 hours, 68(73.8%) and deliveries conducted by |

| |untrained birth attendant, 57(60.5%) . Sepsis related mortality was 14.2% .1 |

| |In a cohort study of Haeri and Baker, objective was to identify potentially modifiable risk factors and causes for febrile morbidity in|

| |teenage mothers. all cases of febrile morbidity using the United States Joint Commission on Maternal Welfare definition in a cohort of |

| |teenage deliveries over a 4-year period at one institution. Of the 730 included teenage deliveries, 49 (7%) women suffered postpartum |

| |febrile morbidity. The overall incidence is 2.5%, higher among caesarean deliveries 4.79%. Higher maternal pre-pregnancy body mass |

| |index (BMI: 34.0 ± 8.6 vs 30.3 ± 6.0 kg/m(2), p = 0.0001), caesarean delivery (RR 21.3, 95% CU 8.9-54.9) and postpartum haemorrhage |

| |(RR 3.0, 95% CI 1.1-6.7) were associated with postpartum febrile morbidity. The maternal morbidity was 6.25% due to puerperal sepsis.9|

| |A prospective study identified infection after vaginal delivery by clinical and laboratory examinations prior to discharge from |

| |hospital and again at six weeks postpartum in Ho Chi Minh City, Viet Nam, symptomatic and verbal autopsy definitions were used for |

| |classifying infection. In total, 978 consecutive, eligible consenting women were followed up at 42±7 (range2-45) days postpartum (not |

| |associated with incidence). 98% took 'prophylactic' antibiotics. The most conservative estimate of the incidence of postpartum |

| |infection was 1.7%. The incidence of serious infection was 0.5%, but increased to 4.6% when verbal autopsy and symptomatic definitions |

| |were used. 10 |

| |Objectives of the study: |

| |1. To study the prevalence of fever in the postpartum period . |

| |2. To know the etiological factors. |

| |3. To evaluate the risk factors associated with puerperal febrile morbidity. |

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| |7. MATERIALS AND METHODS |

| |7.1 Source of Data |

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| |Study setting:- It is a hospital based study |

| |Design of study:- A prospective observational study |

| |Study population:- 100 women who had a full term or preterm, vaginal or cesarean delivery at KVG Medical College and Hospital, Sullia,|

| |Karnataka, women who delivered at private hospital and admitted to the postnatal ward with complications or for baby sake will be |

| |selected by simple random technique. |

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| |7.2 Method of Collection of Data |

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| |Written informed consent signed by the participant will be taken. |

| |Detailed medical history, reproductive history, general and systemic examination to will be done. |

| |Detailed obstetric history will be noted. |

| |Local examination as under will be performed:- |

| |Lower Segment Caesarean Section Wound examination |

| |Breast examination |

| |External genitalia examination |

| |Per speculum examination |

| |Per vaginal examination |

| |Investigations that will be done according to the requirement will be:- |

| |Complete blood count |

| |Urine routine |

| |Midstream urine culture and sensitivity |

| |Blood culture and sensitivity |

| |Ultrasonography |

| |Discharge from surgical wound site – culture and sensitivity |

| |Discharge from vagina and cervical swab taken for culture and sensitivity |

| |Episiotomy wound swab – culture and sensitivity. |

| |Peripheral smear for malarial parasite. |

| |Widal test |

| |Clinical Diagnosis |

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| |INCLUSION CRITERIA : |

| |All women who had a full term or pre term,vaginal or caesarean delivery at KVG Medical College and Hospital, Sullia ,Karnataka. |

| |Women who delivered at private hospital and admitted to the post natal ward with complications or for baby sake. |

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| |EXCLUSION CRITERIA : |

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| |History of fever prior to delivery and continued in the postnatal period. |

| |2. Patients having fever first 24hrs of delivery. |

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| |STUDY DESIGN: Prospective observational study. |

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| |STUDY AREA: K V G Medical College Hospital, Sullia. |

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| |STUDY PERIOD: One year. : Between January 1st 2014 to December 31st 2014. |

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| |SAMPLE SIZE : |

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| |Hundred women who had a full term or preterm, vaginal or caesarean delivery at KVG Medical College and Hospital, Sullia, Karnataka, |

| |women who delivered at private hospital and admitted to the postnatal ward with complications or for baby sake will be selected by |

| |simple random technique. |

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| |FOLLOW UP : Nil |

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| |FOLLOW UP PERIOD : Not Applicable |

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| |STATISTICAL ANALYSIS : |

| |Chi square test and other appropriate statistical methods. |

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| |7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please |

| |describe briefly. |

| |Yes. |

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| |Investigations |

| |Complete blood count |

| |Urine routine |

| |Midstream urine culture and sensitivity |

| |Blood culture and sensitivity |

| |Ultrasonography |

| |Discharge from surgical wound site – culture and sensitivity |

| |Discharge from vagina and cervical swab taken for culture and sensitivity |

| |Episiotomy wound swab – culture and sensitivity. |

| |Peripheral smear for malarial parasite. |

| |Widal test |

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| |7.4 Has ethical clearance been obtained from your institution in case of 7.3? |

| |Yes, Ethical Committee Clearance copy enclosed. |

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| |8. LIST OF REFERENCES |

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| |1.Shamshad, Saadia Shamsher, Bushara Rauf. Puerperal Sepsis-Still A Major Threat For Parturient. J Ayub Med Coll Abbottabad 2010; |

| |22(3):p18-22. |

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| |2.Sweet RL,Gibbs RS. Postpartum infections. Infectious diseases of the female genital tract. Williams and Wilkins 1985:Ch 17 |

| |,p277-93. |

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| |3. Glackin K G, Harper M A. Postpartum Pyrexia. Obstetrics gynaecology and Reproductive Medicine2012; 22(11):p328-29. |

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| |4. Mehta et al. Infection control in delivery care units, Gujarat state, India: A needs assessment. BMC Pregnancy and Childbirth 2011; |

| |11:37. |

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| |5. Harper M A. Postpartum pyrexia of unknown origin. Obstetrics Gynaecology and Reproductive Medicine2009;20(2):p57-62. |

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| |6. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse, Spong. Puerperal Infection. Williams Obstetrics 23rd ed McGraw-Hill 2010; |

| |p661-72. |

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| |7. Daftary S N, Chakravarti S, Daftary G S. Abnormal Puerperium. Manual Of Obstetrics 2nd ed VII Elsevier2007; p433-34. |

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| |8. Yokoe D S. Epidemiology of and surveillance for postpartum infections. Emerging Infectious Diseases September-October |

| |2001;7(5):p837-41. |

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| |9. Haeri S, Baker AM. Estimating risk factors and causes for postpartum febrile morbidity in teenage mothers.J Obstret Gynaecol 2013 |

| |Feb;33(2):p149-51. |

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| |10. Ngoc NTN , Sloan N L, Thach T S, Liem L K B, Winikoff B.Incidence of Postpartum Infection after Vaginal Delivery in Viet Nam. J |

| |Health Popul Nutr 2005 Jun;23(2):p121-30. |

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|9. |

|SIGNATURE OF CANDIDATE |

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|10. |

|REMARKS OF THE GUIDE |

|This is a useful study to see cause of maternal morbidity in puerperium. |

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|11. |

|11.1 NAME AND DESIGNATION OF GUIDE |

|DR.GEETA DOPPA |

|HOD AND PROFESSOR |

|DEPT. OF OBSTRETICS AND GYNAECOLOGY |

|K.V.G. MEDICAL COLLEGE SULLIA |

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|11.2 SIGNATURE OF THE GUIDE |

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|11.3 HEAD OF THE DEPARTMENT |

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|11.4 SIGNATURE OF THE HEAD OF THE DEPARTMENT. |

|DR.GEETA DOPPA |

|HOD AND PROFESSOR |

|DEPT. OF |

|OBSTRETICS AND GYNAECOLOGY |

|K.V.G. MEDICAL COLLEGE SULLIA |

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|12. |

|12.1 REMARKS OF THE PRINCIPAL: |

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|12.2 PRINCIPAL SIGNATURE |

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|ETHICAL COMMITTEE CLEARANCE |

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|1. |

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|TITLE OF DISSERTATION: |

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|“THE PREVALENCE AND CLINICAL SIGNIFICANCE OF FEBRILE MORBIDITY IN POSTPARTUM PERIOD” |

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|2. |

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|NAME OF THE CANDIDATE: |

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|DR. RUMA DUTTA |

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|NAME OF THE GUIDE: |

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|DR.GEETA DOPPA |

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|4. |

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|APPROVED/NOT APPROVED: |

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|APPROVED |

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|LAW EXPERT |

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|Mr. KRISHNAMURTHY, Advocate. |

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|THE PRINCIPAL |

|K.V.G MEDICAL COLLEGE, SULLIA.DAKSHINA KANNADA |

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[pic]

|INFORMED CONSENT |

|I, Dr. RUMA DUTTA, PG student, Department of Obstetrics and Gynaecology is conducting a research work for award of M S Degree Obstetrics |

|and Gynaecology. |

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|The Topic for the Study |

|“The Prevalence and Clinical Significance of Febrile Morbidity in Postpartum period.” |

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|Objectives : |

|1. To study the prevalence of fever in the postpartum period in KVG College and Hospital. |

|2. To know the etiological factors. |

|3. To evaluate the risk factors associated with puerperal febrile morbidity. |

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|I hereby state that the study procedures in details were explained and all questions were fully and clearly answered to the participant / |

|his/her relative. |

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|Investigator’s Signature: |

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|Date : |

|Place: |

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|Contact Address: |

|Dr. Ruma Dutta |

|Post Graduate Student |

|Department of Obstetrics And Gynaecology |

|K.V.G. Medical College and Hospital, Sullia |

|Contact Number : 9738332283 |

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|I have been told in a language that I understand |

|( ) about the study. |

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|I have been explained that the investigation done are the purpose of research, that my participation is voluntary and I/he/she reserve the |

|full right to withdraw from the study at my own initiative at any time, without having to give any reason and that right to participate or |

|withdraw from the study at any stage will not prejudice my/his/her, rights and welfare. I have been assured that confidentiality will be |

|maintained and only be shared for academic purposes. |

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|I hereby give consent to participate in the above study. I am also aware that I can withdraw this consent at any later date if I wish to. |

|This consent form being signed voluntarily indicating my agreement to participate in the study until I decide otherwise. I understood that I |

|will receive a signed and dated copy if this form. |

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|I have voluntarily signed this consent form before my participation in this study. |

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|Signature of the research subject: |

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|Date: |

|Place: |

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|Signature of the witness |

|Date: |

|Place: |

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|PROFORMA |

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|The Prevalence and Clinical Signifcance of Febrile Morbidity in Postpartum period. |

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|Name: Age: IP No: |

|W/o: Occupation: DOA: |

|Socioeconomic Status: Booked/ Unbooked: DOE : |

|Address: |

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|Chief Complaints: |

|H/O fever- Post natal day – |

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|HOPI: fever associated with chills and rigor |

|- Diurnal variation |

|- Low / high grade |

|- Associated with malaise |

|- Associated with cold, cough, headache |

|- h/o increased frequency and burning micturition |

|- h/o lower abdominal pain , discharge from wound site |

|- h/o diarrhoea / vomiting |

|- h/o pain in the breast |

|- h/o pain at vulval site |

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|Obstetrics History: |

|ML Months/years Consanguinity : Yes/No |

|Mode of delivery – vaginal – home/hospital |

|H/O discharge per vagina /leaking per vagina /bleeding per vagina |

|Induction – yes/no |

|Instrumental – Indication |

|LSCS – Elective/Emergency |

|Living/Still born/Dead/ Single /Multiple |

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|Menstrual History: |

|Menarche: _____________years. |

|Past cycles: Regular / Irregular ______ days of flow __________ days of cycle. |

|LMP: EDD: POG: |

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|Past History: |

|H/o HTN/DM/TB/Asthma/Jaundice/ Heart Disease/Drug Allergy/ Previous surgery |

|History of fever |

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|Personal History: |

|Diet: Bowel and Bladder: |

|Appetite: Sleep: Habits: |

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|Family History: |

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|General Physical Examination: |

|General Condition: Built: Height: Weight: |

|Pallor/Icterus/Lymph nodes/Edema of feet/Cyanosis |

|Breast: Thyroid: Spine: |

|Vital Data: |

|Pulse Rate: Blood Pressure: Respiratory Rate: Temperature: |

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|Systemic Examination: |

|CNS: |

|CVS: |

|RS: |

|P/A |

|Uterus ___________ weeks |

|Involuting/subinvolution, tenderness |

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|P/S: Lochia healthy/foul smelling |

|Cervix – healthy /unhealthy |

|Cervical OS –open /closed |

|Bleeding Yes / No |

|Retained products |

|P/V – uterine size – Anteverted/ Retroverted |

|Tenderness in fornices, uterus tenderness on palpation. |

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|Local examination |

|Breasts |

|Episiotomy wound |

|LSCS wound |

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|Investigations: |

|- Complete Blood Count |

|- Urine routine |

|- Urine Culture sensitivity |

|- Discharge from wound Culture sensitivity |

|- Cervix and vaginal swab Culture sensitivity |

|- Blood Culture sensitivity |

|- Imaging technique/USG |

|- Peripheral Smear for Malarial Parasite |

|- Widal Test |

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|Impression: |

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|Signature of patient Signature of witness |

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