ANTENATAL ASSESSMENT - 5

Name:- Kavitaben Mohanlal Patel Age:- 29 years

Registration No:- 456932 Date:- 4 /8/21
L.M.P.:- 5/1/21 E.D.D:- 12/10/21
Obstetrical Score: G1 P0 L0 A0
 MEDICAL HISTORY:
Anaemia: Present Heart Disease:- Absent
Pulmonary Disease:- No any Allergy:- No any
Other:- No any *H/o: RTI/STI/HIV:- No
any

 FAMILY HISTORY:
Type of Family: Nuclear: Yes No. of Persons: Four
Joint........................... No. of Persons:...........................

 PERSONAL HISTORY:
Diet: Vegetarian Addiction: No any
Likes: Drawing Dislikes: No any
Bowel: Irregular Bladder: Increased
frequency of micturation
Tetanus Immunization: Taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income:
Education: Husband – B.Com Wife: 12th pass
Occupation: Husband – Job Wife: House wife
  MENSTRUAL HISTORY:
Menarchy: At 14 years Duration: 5 days
Interval: 27 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 25 year Years Married: 4
years
Consanguineous: no

 PAST OBSTETRICAL HISTORY:

Sr. Year Full Pre Abortio Type Baby Re

No. term term n of Sex Alive Stillborn Weight mark
Delive
ry

Nil

 GENERAL EXAMINATION:
General Condition: Normal Temperature: 37.5 c
Pulse: 82 bpm Respiration: 20/min
Blood Pressure: 120/70 mmhg Other Features: No
any
Pallor: Present Oedema: Absent
Icterus: Absent Lymphadenopathy: Absent
Breasts: Right: Normal Left: Normal
Nipples: Right: Everted Left: Everted
  SYSTEMIC EXAMINATION:
1. Nervous System: Patient is conscious and no any symptoms related to
nervous system
2. Cardiovascular System: S1 & S2 heard with the blood pressure of
120/70mmhg.
3. Respiratory System: Patient has respiratory rate of 20/min with the
normal lung sounds
4. Gastrointestinal System: Patient has regular bowel movements and
no any other complains related to GI system
5. Reproductive System: Uterus is enlarged at size of 28cm and the
abdominal girth is 66cm. The uterus is soft
6. Musculo-skeletal System: The patient has complain of back pain and
leg cramps
7. Integumentary System: The presence of chloasma with linia nigra

 OBSTETRIC EXAMINATION:
Date Weight B.P. Urine Fundal Abdom Uterin Presen FHR Posi Re
mmHg Protei Gluc height inal e tation (bpm tion mar
n ose (cm) Size Size ) k
(cm) (wks)
4/8/ 68kg 120/7 absent abse 28cm 66cm 28 Breech 120 RSA
21 0mmh nt weeks bpm
g

 INVESTIGATIONS:
Blood group: A positive Rh: Positive
 Haemoglobin: 9.5 gm/dl VDRL:
Negative
HIV: Negative Others: No any

 TREATMENT GIVEN:
Calcium 500mg 2BD
Iron 40mg 2BD

 HEALTH EDUCATION:
I have given health education on following points:
 Regular follow up for antenatal check-up
 Regular administration of given drugs
 Care during antenatal period
 Dietary requirements during antenatal periods and
maintenance of GI symptoms
 Antenatal exercise