ANTENATAL ASSESSMENT - 13

Name:- Meenaba Pradeepsinh Jadeja Age:- 23 years

Registration No:- 456788 Date:- 5/8/21
L.M.P.:- 1/2/21 E.D.D:- 8/11/21
Obstetrical Score: G1P0L0A0

 MEDICAL HISTORY:
Anaemia: Absent Heart Disease:- Absent
Pulmonary Disease:- Bronchial Asthuma Allergy:- Absent
Other:- Absent *H/o: RTI/STI/HIV:- Absent

 FAMILY HISTORY:
Type of Family: Single..................... No. of Persons: .......................
Joint: Yes No. of Persons: 5

 PERSONAL HISTORY:
Diet: Vegetarian Addiction: Absent
Likes:Pulav rice, Dal fry Dislike: Bringer
Bowel: Regular Bladder: Regular
Tetanus Immunization: 1st dose of Inj. T.T taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 22000
Education: Husband: 10th pass Wife: 7th pass
Occupation: Husband: Business Wife: Housewife
  MENSTRUAL HISTORY:
Menarchy: At 13 years of age Duration: 5 days
Interval: 28 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 21 year Years Married: 2 years
Consanguineous: no

 PAST OBSTETRICAL HISTORY:

Sr. Year Full Pre Abortion Type Baby Re

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

Nil

 GENERAL EXAMINATION:
General Condition: Normal Temperature: 96.5 F
Pulse: 80/min Respiration: 18/min
Blood Pressure: 110/80 mmhg Other Features: No any
Pallor: Absent 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 no any symptoms related
to nervous system
2. Cardiovascular System: S1 S2 heard with the blood pressure of
110/80mmhg
3. Respiratory System: The respiratory rate are 18/min with normal lung
sounds
4. Gastrointestinal System: The mother has normal bowel sounds and no
any symptoms related to Gastrointestinal system
5. Reproductive System: The size of uterus is increased at 24cm with the
abdominal girth of 55cm. The uterus is soft
6. Musculo-skeletal System: The patient has normal tendon reflexes and
muscle strength.
7. Integumentary System: The presence of chloasma and linia nigra

 OBSTETRIC EXAMINATION:
Date Weight B.P. Urine Fundal Abdom Uterine Present FHR Posit Re
mmHg Protein Gluc height inal Size ation (bpm) ion mar
ose (cm) Size (wks) k
(cm)
9/8/2 62kg 110/80 Absent Abse 24cm 55cm 24 - 110bp -
1 mmhg nt week m
and 8
days
 INVESTIGATIONS:
Blood group: B Positive Rh: Positive
Hemoglobin: 12gm/dl VDRL: Negative
HIV: Negative Others: No any

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

 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