COMMUNITY IDENTIFICATION AND DIAGNOSIS

OBJECTIVES

After going through this practical you should be able to:

Explain importance of community identification
Locate the sources of information for community identification
Use the different methods for collecting data related to community identification
Prepare/write a community identification report
Prepare an action plan based on the information collected from the community

INTRODUCTION
As a community health nurse you have to practice in verity of geographical locations. Each
community, wither urban sub urban, or rural has its unique characteristics, strengths and limitations. As gain
knowledge about the community, u can play a significant role in creating awareness among community
about improving their health status by improving the health practices of its people. This practical will help
you to learn the steps of community identification and develop a community profile. You will learn a
systematic way of gathering data about the community assets and liabilities in terms of community health
and illness. You will be able to identify the relation ship between the data gathered and the health and well
being of the community. You should try to identify biological, physical, socio-economic and cultural factors
that have influence on the health sates of a particular community.

COMMUNITY IDENTIFICATION
It involves the exploration of the varies aspects of the community, related to health and welfare of
the people in order to provide effective services to the community.

PURPOSE:
Systematically gather health related data about a selected community
Explore boundaries of community
Identify health and health related recourses in the community
Identify community assets and liabilities
Examined relation ship between data gathered and health and wellbeing of the community
Recorded the health conditions that are treads to specific population groups in the community.
Identify biological and social forces that have bearing on health of the community.

INDICATIONS:
Develop acquaintance with the community
Identify its recourses for maximum utilization to optimize the health and welfare of the community.
Assess health needs
Plan, implement and evaluate health care
Collect data for community nursing action
CONSIDERATION OF COMMUNITY HEALTH DIAGNOSIS
There are three interdependent, interacting and constantly changing conditions.
Which include
The health status of the community including the vulnerability level of population community health
capability or the ability of the community to deal with its health problems.
 Community health action potentials or the ways and direction in which the community is likely to
work on its health problems.
Communities have their own styles of response
Some community tends to organizes for health care on a community wide basis with plans and
action design for the city or country or state has a whole.
Other focus on area wise planning with considerable diversity

Articles/ equipments required for community identification

It includes
Observation check list
Key information registers
Meeting place or meeting room for community leaders
Community leaders views
Interview schedule
Questionnaire
Map of geographical area
Measuring tools such as weighing scales, thermometer, blood slides, needles

Procedure and guidelines:

As a community nurse you should follow fallowing steps together information about community
Obtain a map of community
Go around the local community to gain first hand impressions of the layout of the area, housing,
spacing of residence, roads, environmental conditions , business and industrial establishment ,
neighbor hood services, educational, recreational facilities, health institutions, private and
indigenous parishioners, community resource for water and sanitation, fuel and food , law and order.
Make a village walk along with health workers
Meet community leaders and influential people
Meet mahila mandals and other woman groups
Visit various institutions
Co ordinate with other related sectors to get information

Guidelines for community identifications

a. The health status.

1. geographical characteristics
 name of the locality or the area
 boundaries
 important roads, streets, buildings, establishments, offices
 impotent land marks
 seasons and months
 prepare a map of the area
 total area
2. demographic characteristics
 total population
 total families
 average size of the families
  Number and characteristics of those functioning below their potential health level.
Population distribution according to
- age
- sex
- education
- occupation
- income
- caste, religion, language
Vital health and events
- birth rate
- death rate
- infant mortality rate
- morbidity rate
- specific morbidity
Special health groups
- infants
- pre scholars
- school going children
- antenatal mothers
- postnatal and lactating mothers
- high risk antenatal mothers
- vulnerable families/multi problem families
3. environmental characteristics
 houses
- number
- type
- living space for head
- other facilities in the home environment
 bathing
 kitchen
 toilets
 electricity
 purity of air
 water supply- safe/unsafe
 water and waste disposal
- collection and removal of solid waste
- collection and removal of liquid waste
- vector control measures
- environmental sanitation
 structural organization for environmental sanitation services
 educational opportunities
- schools
- colleges
- vocational institutions
b. Health capability
It is represented by the degree to which community is able to cope with its health problems and needs
 Resources
 Economic resources of community
- Major occupation, average family income, per capita income
 Institutional resources
- health and health allied agencies
- hospital beds
- nursing homes and other community health facilities
- equipments used are sufficient or not
- safe, wither qualified and supervised by senior safe or not
- resources available at all the times or not
- provision for specialized or referral services
- educational agencies
- social welfare agencies
- industrial and commercial agencies
- recreational and resources
 Human resources
Formal
- professionals –doctors, medical specialist, generalist
- private practitioners, nurse, ANM’s teacher, lawyers, Para- professional, traditional health worker
and indigenous practitioners
Informal
- Senior citizens, influential person’s woman and man, persons giving care for the families, neighbors (home
nursing)
 Natural resources
-land, water, soil etc.
c. Health action potential
Community health action poetical effects health planning as such community will refer in its patterns of
health action depending on the value that people assign to health as comp aired to their other life needs
and the characteristic way of taking action. The political system by which they govern themselves and
their habits they have developed with respect to social action.
 Health knowledge, believes and practices
About health and disease
- out look on cause of disease, spread and prevention of disease
- existing health practices related to prevention, care fro some specific illness
- superstitions related to food, child care and health practices
- promotional health practices, food, rest, relaxation, recreation, games etc.
- attitude towards health agencies –positive or negative to community health programmes and
community organizations
 Social environment health problems as felt by the community
 Community organizations
 Trade union organizations
 Statutory bodies
 Leadership patterns
 Channels of communication
 Factors that can help or hinder community health actions
Sources of these information
 - health and health allied resources
- community people
- community leaders – formal or informal
- census record

Preparing a report on community profile

Report prepared about community profile should be such that all health team members and related team
members can use it. It should include all facts and figure of information colleted. A brief report helpful in
orientation to new staff and planning for future services.
Check your progress
Tick ( ) makes the correct answers
1. objectives of community identification are
a) understand community
b) explore community boundaries
c) prepare community profile
d) identify community resources
e) all the above
2. demographic data can be obtained from
a) census record
b) school attendance record
c) hospital admission data
3. which are the most important vital event rates
a) birth, death and illness
b) birth married and illness
c) death, migration and illness
4. which of the following community characteristic have impact on the community health status
a) physical and geographical boundaries
b) the people
c) political structure
d) economic status
e) all of the above
Answers to check the progress:1.e 2.a 3.a 4.e
 PREPARING A MAP OF THE COMMUNITY

OBJECTIVES:
-locate the general and specific sources from the were the maps are available such as general stores,
panchayat office/ corporations/block development offices/district offices etc.
- develop a map of your area with the help of map which is available with the block/district office
- make use of the map to render services in the community
- identify the distance from one area to the other, from the scale given in the map
- enlarge the map if required for clarity and additional information

INTRODUCTION:
As a community health nurse you are expected to render holistic care to the individual family and
the community at large. This requires a lot of traveling from one place to the other in order to visit the
families which may be situated far way from your centre

Preparing A Map Of The Community

use of preparing map

prevents the wasteage of time spent in identifying the resources
helps in the judicious allot ment of time and prier planning of work schedules
seek assistance from local leaders and liaison with them without difficulty
gives an idea about the location, direction and distance to be traveled to reach the people
help to know about resources and facilities in the community

indication for preparing a map of the community

- important updated information about the community is not available
- indication of the boundaries of the sub – community ,housing,wells,roads etc ., is not specified
- resources and organizations in the community, eg: health centers, schools, shops, panchayat office
etc,are not indicated
- data regarding the quantum of work is to be completed
- provide guidance and direction to familiarize the health workers with the area in order to plan health
activities
points to remember
- draw map according to the scale, i.e ., if the scale given is 1 cm = 1km then the place which is 10
kms away from the centre should be marked at 10 cms
- give appropriate symbols to indicate the place and give the key on the lower corner for eg: the
symbol shows railway line
- mark the directions in the map using stranded abbreviations
- keep the map updated by making necessary modifications corresponding to the changes occurring in
the community
- make the directions on the map so that a person referring to the map understands which side of a
map faces north -south-east –west
- place the map of the community on the board in the community health centre for ready reference and
guidance
articles required for preparing a map
 - a map of the block or the village which may be available with the block/ development office/
corporation office/census offices etc.
- chart paper/ graph paper
- stationary items such as pen, pencil, eraser, scale, tap measure
procedure
- survey the area
- Locate the distinct places or institutions of the community like schools, temples, health facilities,
housing, complexes.
- Prepare a road map during the survey
- Note down the time of commencement of journey and reaching time
- You can use the time scale to plot the graphite, if the time taken to reach the nearest school from the
PHC takes 15 minutes (X = 15 MINUTES) and to reach the nearest temple takes 30 minutes, the
distance should approximately 2X . if we could measure x than we can easily calculate 2X, 3X or
NX. But for this standardization of means of continent and spread should be kept in mind
- Carry a compass to find out the direction
- Join the road map to get a complete diagram of the community
- Hilet the places of significant to the health worker such as school, hospitals, market places,
community hall, meeting places such as chaupals etc.
- Take necessary health from the local people to understand the area in a better way.

ENLARGING THE MAP

Steps
- first draw the lines ( in light pencil) to from equal squires over the map area which you want to
enlarge
- then draw same number of squares but larger ones on another sheet of the paper
- Copy the map square by square. You will have an enlarged map
- in this figure you have a square of 1cm drawn over the map. Then on the other sheet of paper, large
square are drawn and accordingly filled in thus gives as a map exactly the double in size from the
previous map. The scale of this enlarged map is 1cm =2kms.
- This map can be used to make more information which may be available with the other health team
members of the community. As and when there is new information about the community such as
new set of houses, institutions, or other resources, these may be marked on the map to keep it
updated. This enables the community health nurse to periodically evaluate the improvements in the
health status of the community.
Placement of the map
- Map can be placed on the bulletin board in the health center for ready reference by the workers. The small
version of these maps can be carried by the workers with them for their daily field work.

COMMUNITY HELATH ACTION PROGRAMME

OBJECTIVES
- obtain community support and utilize its resources to promote healthy living
- Select the most appropriate method and media for educating the people about health.
- Plan, organize and implement health activities fro groups of peoples based on their needs.
- Carryout the steps for organizing the community health action programme
- Encourage the people to adapt and sustain health promoting lifestyles and practices
 - Equip the community with sound and adequate knowledge to deal with their problems
- Achieve health development through individual and community effort
- Promote self reliance among the community.

INTRODUCTION:

Community heath action programme is concerned with the change in knowledge, attitude and behavior
of people, there by making relative improvements in their basic quality of life by promoting desired health
behaviour.
In order to implement any CHAP with the help of community participation, you may select community
representatives from political, social, professional, religious and other groups. The community should be in
constant touch with the health tem support and guidance.

ORGANISING COMMUNITY HEALTH ACTION PROGRAMME

Various aspects of organizing community health action programme as fallows

Points to remember
- Involve individuals, families, and community in planning and implementing the chap.
- Find out the peoples needs, concerns and priorities of the community
- Utilize community or local resources for imparting health education such as media of community
most frequently accepted and used.
- Monitor and evaluate to assess the out come of the programme. The programme may be pre planned
as new problems are observed or if previous strategies have failed to bring about the desired results.
- Fallow systematic approach using the basic steps of the concepts os the nursing process such as
assessment, need identification, objective setting, planning, implementing and evaluating the
strategies.
Equipment
- suitable place /building/tents for privacy
- setting /waiting room
- cold chain felicities- ice line refrigerators
- vaccines, syringes, needles antiseptic solutions
- immunization registers and individual health cards
Procedure
-collection of base line information.
-analyzing the collected information to identify the needs.
-settings priorities and formulating objectives.
-identify and securing community resources.
-planning action and implementing the plan.
-evaluation of services renders.

STEPS:
A) collecting information
- The information collected should highlight the health needs/problems. The collected data
should be authentic and based on real facts. Various methods of collecting information can
be utilized such as:
1. History taking
 - it is carried out with this specific purpose for e.g.,you would like to identify the nutritional
status of the family, so in this case you would like to know the family’s food habits, intake,
likes and dislikes and also you can see from the availability of food stuff in the home
environment and amount of expenditure incurred in the food.
2. Observtion
- It should be purposive and depends on the aim of observation for e.g., observing the
mother how she breast-feeds her newborn baby, hygienic practices etc.
3. Inestigation
- It aims to ascertain the actual persistence of the problem, for, e.g., HB testing in case of
fatigue and tiredness, in doubt of anemia, as in Antenatal cases.
4. Interviewing
- It provides relevant information for future interactions thereby to develop a trusting
relationship with the individual and family and community at large, e.g., interviewing the
family on acceptance of family planning.
5. Review of previous records
- Records provide a storehouse of information, based on the area of study, you can
identify the nature of problems with which people come to the health facility, their disease,
problems such as fever.
6. Follow up.

B) Identifying needs / problems in community.

After collecting the information form various sources in the community you have to analyze the
information collected from various sources. You as a health worker should consider the cause and
associated factors responsible for the problems, magnitude of the problem and also the severity of the
problems identified. The needs of the people should be addressed in such a way that they lead to
reduction/relief of the problem which have caused it, so that it does not continue to be a problem any
more.
For e.g., if you have identified that many children are suffering from diarrhoea (as a problem) from
the information you have collected, you need to collect further data related to:
- probable cause of diarrhoea
- feeding/eating habits
- water supply safe water supply
- personal hygiene
- presence of helminthes infection
- environmental sanitation

C) Setting priorities

1. Setting priorities

Their may be multiple problems which the community may be facing and it is not humanly possible to
deal with all the problems at the same time. Hence, priorities have to be set based up on the seriousness and
magnitude of the problem. It is not easy to establish which is they most important need has all may warrant
equal attention at the same time their fore the fallowing factors should considered to address the priority
needs.
- Nature of the problem, how fast it can spread of its natural history
 - Prevention potential of the problem
- Modifiability of the problem
- People concern about the problem
- Extent of the number of the persons effected by the problem in the community
- Vulnerable groups effected by the problem
2. formulation of objectives
After deciding the priorities, the objectives should be formulated; the objective should aim at the
improvement of the health of the people.
The objectives
- clear and specific
- measurable
- sated in terms of people out come
- community oriented
- time oriented
- attainable and practicable

D) Identifying and securing community resources.

In order to plan and implement CHAP community resources should be identified. Resources include
people, time, money and materials required for the successes of CHAP for smooth functioning.
Resource can be obtained from with in or outside the community. Resources with in the community
include those which are required to hold discussion, role play health education or to render the services
eg: place, vehicles, manual places, electricity infrastructure with setting capacity and working
environment.
E) Plan of action and implementing the plan.
After the identification and enlisting the needs and problems. a plan should be made which
includes
- the statement of objectives
- selection and organization of content
- methods and media for delivery of content or services
- Preparation of schedules which need to be time and activities specific. In any mask health
education programmes one must fallow the basic principles of health education
Selection of content: the content should be
- relating to the objectives
- Logically and systematically arranged to cover the topic in an easy and logical manner for
better comprehension.
- Use of different methods of presentation
- Selection appropriate audio visual aids- projected and non projected
- Wholesomely covered and essentials conveyed to the masses.
The method should be selected according to the situation and the problem being tackled. While selecting
the content fallowing few points need to be kept in mind
- number of number of people involved
- appropriateness of the method to the local culture and language
- resources available
- suitability of the method according to the people characteristics
Type of mass media that can be used:
- posters
 - exhibitions
- models
- type recording
- news papers ,magazines
- radio
- publications
- street plays
- role plays
- songs, parody
- puppet shows
the use of these methods win how ever depend up on the background up on the audients for eg: if the
group need to be thought skill then the demonstration can be shown to them and for creating knowledge and
awareness among the group,, in formation can be conveyed group posters, discussions, health talks etc.

Preparing schedule of time table:

After identifying the problems in the community and establishing the priorities, stetting objectives and
locating the resources, a time table or a schedule is developed so as to put the plan in to action. It should
reflect clearly as to what we done, where, when, by whom and for whom?
While preparing a schedule, the convince of the people should considered such as transportation, climatic
conditions, location of the CHAP so that maximum number of the people can attend the programme.

F) Evaluation of the services

It is important to fine out the results or out come of the programme the change in the behaviour of the
people should be observed with in a specific time period. Measures adopted by the people fro the prevention
of the problems after the CHAP should be looked for and noted evidence of the reduction in the incidence of
the problem in the record should be accounted. Compare the out comes with objectives which are
observable and measurable.

Recording and reporting:

It is important to record the information which is obtained from the community by observation,
interviewing and reviewing the previous records. Recording all the problems in the community and then
reporting them to the consent health authorities is an important component of the programme.
 REPORTING WRITING

Still births------------- causes----------------

Maternal deaths--------------- causes-----------------

Analysis of causes of death of children

INFANT TODDLER
s.no Causes of death Up to 1 week to 4 weeks to 1 year to Above
1 week 4 weeks 1 year 3years 3years
1 Asphyxia neonatorum

2 Haemorrhagic disease of new born

3 Jaundice

4 Congenital deformity

5 Prematurity

6 Injury,birth or accident

7 Tetanus

8 Pertusis (whooping cough)

9 Diphtheria

10 Poliomyelitis

11 Typhoid
12 Diseases of respiratory system

13 Diseases of digestive system

14 Measles

15 Other exanthematous fever like

chicken pox etc.

16 Encephalitis

17 Marasmus

18 Pyrexia of unknown origin

19 Other causes (specify)

TOTAL

Signature of medical officer in charge

 MUNICIPALITY CORPORATION OF DELHI
(Health department)

E.P.I MUNTHLY SURVEILANCE AND VACCINATION

(Including prophylaxis programme) PERFORMANCE REPORT

Sate/U.T---------------------------------------- Month --------------------

Name of the unit (maternity home/MC-FW Centre) ---------------------------------------------

No. of reporting units in the state--------------------------------------------------------------------

No. of unit for which report is being submitted---------------------------------------------------

A. surveillance:

Number reported

Diseases For the month Cumulative since april

Cases Deaths Cases Deaths

Diphtheria
Pentusis
Tetanus neonatorum
Tetanus other
Poliomyelitis
Tuberculosis ( childhood)
Measles
Typhoid fever

b. vaccination performance:
Vaccine dose No. of beneficiaries Cumulative
during the since april
 reporting month
Below Above 1 Below Above
1 yr yr 1 yr 1 yr
T.T ( expectant mothers) 1st
16 – 36 wks. 2nd
( for subsequent pregnancy) booster
D.P.T ( For infants 3 – 9 1st
months) 2nd
Child ( 18- 24 months) booster
Polio (for infant) 1st
2nd
3rd
Child(18-24 months) booster
Measles (270 days
-12
months)
B.C.G ( for infants – one
dose) at birth
 MUNICIPALITY CORPORATION OF DELHI
(Health deportment)

Monthly statement of work for the month/year ---------------------------------------------------

M&CW-FW centre -------------------------------- zone---------------------------------------------
------------------------------------------------------------------------------------------------------------

No. Carried froward from previous month/year

New admitted during month/year
Total under care during month/year
(Transferred from AN to PN infant to toddler. Toddler S.C.)

Closed by:

(Through death)
(Left district)
(Other reasons)
(Total closed)

Carried over to following month/year

A.N cases 1st visits Clinic attendance Home visits
revisits
Infants 1st visits
revisits
Toddler 1st visits
revisits
Confinement by Homes
centre staff Wards
Total

Houses visited ----------------- Hours of P.N-------------

Hours of visits -----------------
S.T.S donetoatl----------------- Positive -------------------
Treated -------------------------- No. of children -----------
No. of cases of diarrhoea reported in the age group of (0-5 yr)-----------------------------------
Advised O.R.S/ORT
No.of Drs. Clinics----------------
Health talks given by Drs-------------------- LHVs----------------------- Attendance------------
No.of calls attended by Doctors ----------------------- LHVs--------------------------------------
 MUNICIPALITY CORPORATION OF DELHI
(Health deportment)

MONTHELY PROGRESS REPORT ON ORAL CONTRACEPTIVES PROGRAMME

a) general information
1. name of the state/UT/Organ ------------------------------------------------------
2. report for the month of ------------------------------------------------------------
3. no. of centers distributing oral
i. PHC -------------------------------------
ii. urban centres---------------------------
4. no. of centres reporting the distribution of oral contraceptives of the month
i. PHC--------------------------------------
ii. urban centres---------------------------
5.i. total no.of oral pill cycle distributed during the month---------------------
ii. cumulative total cycle distributed during the current year----------------
b) orall pill cases
6. number of women continuing on oral pills ( cases) from the last month --------------
7. number of women put on oral pills during the moth( new cases)-----------------------
8.no.of women continuing on oral pills at the end of moth (6+7+8)----------------------
c) stock position
10) quantity of oral pills in stock at the beginning of month----------------
11) quantity of oral pills received during the month------------------
12) quality of oral pills dispatched during the month ----------------
13) balance in stock at the end of the month (10)-(11)-(12)----------------
14) monthly supply of oral pills required -------------------------------------
report of family planning programme
1.report for the month of
2. name and address of the centre
3. name of the agency
4. no. of contraceptive distribution centres /depots
5. population of the centre’s area
6. no.of target couples in the allotted area
7. no.of families surveyed up to the month
8. no.of families resurveyed up to the month
9. no.of families unsurveyed up to the month
10. no. of individuals contacted for different months
service rendered:
1. sterisisation programme
i) total no .of sterilization operations actually got done by the family welfare unit:
rural urban total
tubectomy:
vasectomy:
total:
brek –up
ii) operations done by the centre
 iii) operations done at the camp
iv) name of the hospital where cases
referred and actually got done by
the reporting centre
1)
2)
3)
4)
5)
6)
II) IUCD insertions:
i) total no. of IUCD insertions done------------------------------
Cu.T lippie loop total
rural
urban
total
Cu.T lippie loop total
ii) no. of first IUCD insertions
iii) no. of re-insertions done
iv) no.of removable cases
v) name of the hospital where IUCD cases referred actually inserted the reporting centre
1)
2)
3)
4)
5)
6)
7)
8)
III) conventional contraceptives
Condoms jelly depth F.T O.P
i) no. of new cases started for
ii) no. of regular user
iii) no.of regular users discontinuation
iv) no. of pieces of condom distributed to the vasectomies cases
v) total no. of pieces of conventional contraceptives distributed during the month ( including those
distributed to vasectomiesed person)
a) condoms
b) jelly
c) application
d) dipth
e) P.T
IV) staff position or the family welfare unit
s.no name of posts sanctioned in poison
 Signature of medical officer incharge
With seal and date

-----------------------------------------------------------------------------------------------------------------------

Vaccine dose no. of beneficiaries cumulative since April

D.T (Diptheria & 1st

Tetanus) 2nd

Child (5-6 yrs) booster

i) all women
ii) expectant and nursing mothers
iii) children (1-12 yrs)
b) prophylaxis against nuritonal anemia (COMPLETED)
i) all women
ii) expectant and nursing mothers
iii) children (1-12yr)

c)prophylaxis against blinedness among children caused by vitamin A deficiency

no. of children covered cumulative total of children
during the month under up to and including the reporting
report the financial year

children ( 1-5 yrs)

i) initiated
ii) continuing
iii) completed

dated ------------------------------------- signature of M.O.I/c

of the centre with seal
 NUTRITIONAL ASSESSMENT SCHEDULE
Name
father’s name
age
sex
address
house no
village
district
sate
family history of illness
medical history
surgical history
past history
present history
congenital problems
immunization status

clinical assessment
1. general appearance : normal/thin built/sickly
2. hair :normal/lack luster/dyspigmented/thin and sparse/easily pluckable
3. face : diffuse pigmentation/naso-labial dyssebacea/ moon face
4. eyes: conjunctiva- normal /dry on exposure for ½ min/dry and wrinkled/bilot spot
+/brown pigmentation/angular conjunctivitis/ple conjuctiva
5. lips: normal/angular stomatitis/ cheilosis
6. tongue: normal/pale and flabby/red and raw/fissured
7. teeth: mottled enamel/caries/attrition
8. gums: normal/spongy/bleeding
9. glands:thyroid enlargement/parotid enlargement
10. skin: normal/dry and scaly/follicaular hyper keratosis /petechiea/scrotal and vulval
dermatosis
11. nails:koilonychias
12. edema : in dependent part
13. skeletal system: ricketic/changes-knock knees or bow legs/ epiphyseal enlargement
/pigeon chest
14. internal system: heapto megaly/psychomotor changes/mental confusion/sensory
loss/muscle wasting /loss of ankle and knee jerks/calf tenderness/cardiac
enlargement/tachycardia
antropometric measurements
weight (kgs)
height (cms)
mid arm circumference (cms)
head circumference (cms)
chest circumference (cms)
skinfold thickness (mms)
laboratory investigation:
1. hemoglobin
2. stool for ova and cyst
- negative
- ascariasis
- ancylostomiasis
- giardiasis
- amoebiasis
- strogylodis
- others specify
3. blood smear for malarial, parasites
- negative
- MT/BT
- Filarial
Remarks/refererrals/follow up:

Signature of health worker

Dated signature of supervisor

Practice sheet for recording a physical examination

1. Patient’s name:
2. Vital signs: b.p---------------------- pulse----------------------
weight ------------------- height --------------------
temperature --------------- respiration------------

3. Urine test
4. General appearance: physical,mental,state,speech,ability to walk
5. Skin: note colour,lesions. odema,moisture, scars, injury,temperature
6. Lymph glands: note enlargement,tenderness,redness
7. Head:injury, depression of skull, tenderness over sinus
8. Eyes: changes in the eyelids, movement, pupil reactions, conjunctivae, sclerae,corneas, foreign
bodies or discharge
9. Ear: a) hearing test
b) inspect and palpate out side of ear
10. Nose: inspect outside of the nose,nostrils
11. Mouth and throat: inspect lips, mucous membranes, teeth, gum,throat
12. Neck: inspection position,deformities,movability, thyphoid gland
13. Respiratory system: rate, rhythm, ease of breathing, cyanosis, shape of chest,cough, sputum.
14. Heart
15. Breasts: inspect size, shape, scars, palpate for masses, tenderness,liver,spleen,kidneys,bladder
16. Abdomen: inspect shape,scars,palpate for masses,tenderness,liver,spleen,kidneys, bladder
17. Male genitalia: inspection penis, scrotum, groins, any swelling, redness, tenderness, discharge.
18. Arms and legs: inspect and palpate for odoema
19. Musculo skeletal system: write any deformities, swelling, swelling,range of motion, muscle
tenderness
20. Nervous system: level of consciousness, gait, sensation,neck stiffness, pain on straight leg raising
21. Female genitalia: inspect labia, urethra,vaginal opening, cervix, palpate uterus, adcnexal area.