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High Risk Scoring
High Risk Scoring
ANTENATAL MOTHER
Hospital: Medical college & Hospital Date of Booking: 06/ 02/24 Reg. No. 2304081
ANTENATAL HISTORY COLLECTION
Name: Suhana khatun W/O: sk. Abdul ali Age: 23 yrs
Religion: muslim
Address: Dhulagar mollapara. P.S: sankril
Dist: howrah
Education Class: class 4 pass Occupation: house wife Duration of
marriage: 1.5 yrs
OBSTRETICAL HISTORY: G: 1 P: 0 A: 0 L: 0
Period of gestation in month: 9 months 4 days
History of previous pregnancy: primi
PERSONAL HISTORY: she is non vegetarian and no allergy to food and drug.
GENERAL PHYSICAL EXAMINATION
Pulse : 86 bits/min Respiration: 23 br/min B.P:
124/80 mm of hg.
A. Symptoms
a) Pain: nil
b) Discharge: nil
c) Micturition: frequent
d) Digestion: normal
e) Colic :nil
f) Others symptoms: nil
g) General Health: good
B. Physical Signs
a) Ear & nose: normal
b) Teeth & gum: clean
c) Tonsils & pharynx: normal
d) Breast & Nipple: normal and clean
e) Heart: NAD.
1. f Lungs: NAD.
f) Spleen: not palpable
g) Liver: not palpable
h) Skin: moist
i. Anal region: normal
ii. Valve:normal
iii. Groin: normal
iv. Abdominal wall: striae graviderum
i) Lymphatic: nil
j) General condition: normal
a) Any other sign & symptoms: nil
ABDOMINAL EXAMINATION
Inspection
Fetal movement: present
Skin changes: linia nigra and striae graviderum
Date Fundal height Abdominal Presentation Relative size of FHS/mint
In cm In Girth & position of fetus head to pelvis
weeks
Fundal grip: Not engaged 144b/min
6/2/24 40 cm 33 wks broad ,soft, irregular
90 cm mass. Left lateral grip:
smooth curved mass.
right lateral grip: small
knob like structure
PG1: hard globular
mass.
PG2: convergent
presentation: LOA.
Treatment:
Tablet shelcal 1 tab od
Tablet austrin 1 tab od.
Advices:
To take adequate rest & sleep in left lateral position.
To take nutritious diet
To maintain personal hygiene and wear clean clothes.
To take temporary family planning method.
LABORATORY INVESTIGATIONS:
Hb: 11mg/dl
Blood group/Type: B (-) ve
VDRL:negetive
Blood sugar: 80mg/dl
HIV: non reactive
Urine: no sugar and albumin
USG: cephalic presentation liquor: adequate
Placenta: posterior lower end encroaching the internal os
Impression: primi, weight less than 45 kg and maternal height is less than 145 cm-3+1+1=5