ANTENATAL ASSESSMENT - 6

Name:- Binal Sureshbhai Parmar Age:- 25 years

Registration No:- 245789 Date:- 4/8/21
L.M.P.:- 16/2/21 E.D.D:- 23/11/21
Obstetrical Score: G2 P0 L0 A1
 MEDICAL HISTORY:
Anaemia: Present Heart Disease:- Absent
Pulmonary Disease:- Bronchial Asthma Allergy:- No any
Other:- No any *H/o: RTI/STI/HIV:-
Absent

 FAMILY HISTORY:
Type of Family: Single: Yes No. of Persons: 3
Joint........................... No. of Persons:...........................

 PERSONAL HISTORY:
Diet: Vagitarian Addiction: no any
Likes: handcrafting Dislikes: -
Bowel: Regular Bladder: Regular
Tetanus Immunization: Taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 20000
Education: Husband: B.Sc Wife: B.Com
Occupation: Husband: Job Wife: Job

 MENSTRUAL HISTORY:
 Menarchy: 14 Duration: 5 days
Interval: 28 days Flow: regular

 MARITAL HISTORY:
Age of marriage: 22 year Years Married:
3 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
1 2019 Yes

 GENERAL EXAMINATION:
General Condition: Normal Temperature: 98.9 F
Pulse: 76/min Respiration: 18/min
Blood Pressure: 120/70 mmhg Other Features: no
any
Pallor: Present Oedema: Present
Icterus: no any Lymphadenopathy: absent
Breasts: Right: enlarged Left: enlarged
Nipples: Right: everted Left: everted

 SYSTEMIC EXAMINATION:
1. Nervous System: The mother 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: The patient has complain of dyspnea with
normal lung sound
4. Gastrointestinal System: The patient has regular bowel movements
and no any symptoms related to GI system
5. Reproductive System: The size of uterus is increased at 28cm from
symphysis pubis and abdominal girth is 60cm. The uterus is soft
6. Musculo-skeletal System: The mother has complain of swelling leg
cramps
7. Integumentary System: The skin is hyperpigmanted with presence of
chloasma and 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/ 60kg 110/7 presen abse 28cm 65cm 28 Cephali 112b LOP
21 0mmh t nt weeks c pm
g

 INVESTIGATIONS:
Blood group: AB positive Rh: Positive
Haemoglobin: 9gm/dl VDRL: Negative
 HIV: Present Others: no any

 TREATMENT GIVEN:
 The following treatment is given:
 Calcium 500mg 2BD
 Iron 40mg BD
 Ipotropium Bromide by metered dose inhaler

 HEALTH EDUCATION:
 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