ANTENATAL ASSESSMENT -9

Name:- Minaxiben Jatinbhai Vadgama Age:- 26 years

Registration No:- 657453 Date:- 6/8/21
L.M.P.:- 6/12/20 E.D.D:- 13/9/21
Obstetrical Score: G3 P1 L1 A1
 MEDICAL HISTORY:
Anaemia: Present Heart Disease:- Absent
Pulmonary Disease:- Absent Allergy:-Absent
Other:- No any *H/o: RTI/STI/HIV:- No

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

 PERSONAL HISTORY:
Diet: Vagitarian Addiction: No any
Likes: Handwork Dislikes: -
Bowel: Irregular Bladder: Frequency of
Micturation is increased
Tetanus Immunization: Taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 20000
Education: Husband: B.Com Wife: 12th pass
Occupation: Husband: Business Wife: Housewife

 MENSTRUAL HISTORY:
 Menarchy: 14 Duration: 5 days
Interval: 30 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 20 year Years Married: 6
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 2017 yes FTND Mal Yes 3.8kg
e
2 2019 Yes

 GENERAL EXAMINATION:
General Condition: Normal Temperature: 98.7 F
Pulse: 86/min Respiration: 22/min
Blood Pressure: 130/80mmhg Other Features: No
any
Pallor: Present Oedema: Absent
Icterus: Absent Lymphadenopathy: Absent
Breasts: Right: Enlarged Left: Enlarged
Nipples: Right: Everted Left: Everted

 SYSTEMIC EXAMINATION:
 1. Nervous System: The mother is conscious and there no any
symptoms related to nervous system
2. Cardiovascular System: S1 S2 heard with the blood pressure of
130/80mmhg
3. Respiratory System: The respiratory rate are 22min with normal lung
sounds. The mother has complain of dyspnea
4. Gastrointestinal System: The patient has decreased bowel sounds
with complain of mild constipation
5. Reproductive System: The uterus is enlarged at the size of 34cm and
abdominal girth is 70cm. The mother has complain of lower
abdominal pain. The uterus is soft
6. Musculo-skeletal System: The mother has lower back pain with ankle
edema
7. Integumentary System: The skin is hyperpigmanted with the
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)
6/8/ 80kg 130/8 Absent Abse 34cm 70cm 34 Breech 114b LOP
21 0mmh nt weeks pm
g

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

 TREATMENT GIVEN:
The following treatment is given:
 Calcium 500mg 2BD orally
 Iron 40mg BD orally
 Ibuprofen BD orally

 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