LONG CASE
I am presenting case history of Mrs. _______ age ___yrs ______ by religion ________ by
occupation educated till _________ resident of ________. Her husband is _________ age___yrs
occupation____________ . she belongs to _________ socio economic status.
She was admitted in this hospital on date __________ with chief complaints of
1) Amenorrhoea = _____ weeks
( no of months* 4+1= 1st trimester
no of months* 4+2= 2nd trimester
no of months* 4+3= 3rd trimester)
2) Any other complaints
I. HISTORY OF PRESENT ILLNESS:
a) 1st trimester (upto 12 wks)
1) No h/o excessive vomiting ( hyperemesis gravidarum i.e. pt cannot do work and
there is weight loss and it can lead to IUGR)
2) No h/o burning micturition (UTI can lead to anaemia)
3) No h/o fever, drugs, exposure to radiations (for congenital malformations) , (if
fever if with rash and lymphadenopathy as in rubella or with rigors and chills as
in malaria ) . in pregnancy, amoxycillin, vitamins are safe.
4) No h/o pain abdomen bleeding per vaginuum ( abortion diagnosis and
treatment)
5) h/o UPT , USG ( USG ± 1 wk in 1st trimester
± 2 wk in 2nd trimester
± 3 wk in 3rd trimester
( As 1/3rd pts do not remember LMP so to calculatre fetal maturity)
6) h/o folic acid 5mg/day for 3 months ( to prevent CHF, IUGR , Abortions , PIH,
APH)
nd
b) 2 trimester ( 13-28weeks)
1) h/o quickening
primi at 18-20 weeks (add 20-22 weeks= EDD)
multi at 16-18 weeks ( add 22-24 weeks = EDD)
EDD= 40 weeks
2) h/o TT immunization
(0.5 ml I/M 1ST dose 16 wks
2nd dose 20-22wks)
3) h/o iron calcium tablets
iron from 13 weeks ( 1 tablet per day )
calcium from 20 wks ( or 1 litre milk)
200mg ferson tab with 60 mg elemental iron and 0.5mg folic acid)
4) USG( 18-20wks) – CMF, Foetal maturity, localization of placenta
5) h/o headache ,giddiness, blurring of vision, swelling feet (PIH)
6) h/o pain abdomen, BPV (abortion)
c) 3rd trimester (29-40wks)
1) h/o headache ,giddiness, blurring of vision, swelling feet (PIH)
2) h/o bpv (APH)
3) h/o pain abdomen ( preterm labour)
4) h/o leaking ( PROM)
5) H/O fetal movements (12/day)
After meals breakfast lunch dinner lie in left lateral position for 1hr , fetal
movements should be 3-5/ hour
6) h/o labour pains
II. Treatment history
Treatment in hospital
If pt has delivered then tell vaginal / LSCS
Wt ,sex of baby, immediate cry or not , immunization of baby, urine and stool of baby ,
breast feeding of baby
Puerperium history :
Lochia
Mobile pt
Urine stool passed or not
Feeding
Fever (puerperial pyrexia)
Pain in legs with swelling (DVT)
Problem in stich line
III. Menstrual history
3-4/30 days regular
DLMP -1/1/2020
EDD – 8/10/2020
Add 9 calender months + 7days to the 1st day of las menstrual period = naegle’s formula
If cycles short
3-4/20
DLMP -1/1/2020
Corrected EDD – 28/9/2020
Subtract 10 days from EDD ( days short of 30)
If cycles long
3-4/40
DLMP -1/1/2020
Corrected EDD – 18/10/2020
Add extra days above 30
IV. Obstetric history
No. of years of marriage
G,P,A ,L (male/female)
See high fertility low fertility
Gravida = no of times pt pregnant including present pregnancy
Para = no of times she has crossed 28wks in past
Abortion = no. of times she has aborted in past
If delivery: ___yrs back vaginal/LSCS Wt ,sex of baby, immediate cry or not ,lactation
lactational amenorrhoea, milestones and immunization of baby
If abortion: ____yrs back 1st /2nd trimester if D and C done od not ( scarred uterus leads
to placenta previa)
Contraceptives method used before ( bcz of OCP used if within 2 months after stoppage
if pt becomes pregnant = risk of twins
Contraceptive method she will choose now so that with LSCS tubectomy can be done.
Newly marries use: barrier/ocp
After 1 child : CuT/Barrier
After 2 children: CuT/ Tubectomy
At 3rd LSCS tubectomy must ( acc. To government)
V. Personal history
Smoking ( nicotine being vasoconstrictor leads to IUGR)
Alcohol( >30ml/day leads to fetal alcohol syndrome CMF)
Vegetarian or non vegetarian
VI. Past history
TB
DM
HTN
Surgery, BT
VII. Family history
TB
DM
HTN
VIII. Diet history
Moderate work 50 kg needs 2500 calories in pregnancy
Non pregnant =2200cal
Preg = +300= 2500cal
Twins =+600 =2800cal
Lactating mother 2200+ 500+ 2700cal
What she eats breakfast lunch dinner
1 chappati = 100 cal
1 katori dal= 100 cal
1 katori curd= 100 cal
1 glass of milk = 300cal
100 gm of fruits= 100cal ( except mangoes and grapes =300calories)
1 cup tea = 50cal
Protein= 1gm/kg body wt
Iron = 40 mg/day
Calcium = 1000mg/day ( lactating 1.5gm/day)
Zinc = 15mg/day
Vit c= 70mg/day
Vit A 6000IU/day
Vit D 400IU/day
Thiamine
Riboflavin (1.1mg)
B12(2mg)
Nicotinic acid(17mg)
Adequate = 1ltr milk +6roti+3katori dal+ fruits+ green vegetables
Minimum 250ml milk, 30gm butter,fruits vegetables
EXAMINATION
GPE
Pt conscious , cooperative
Avg built nourishment (well nourished or poor : see hair ,skin)
Height (<4 feet 7 inches risk of contracted pelvis)
Weight – baseline
1 kg in 1st trimester and 500gm/wk in 2nd & 3rd trimester i.e. 5+ 5kg
Total 10-12kg (avg 11kg)
Pallor
Jaundice
Cyanosis
Glossitis stomatitis
Lymphadenopathy
Thyroid enlarged or not
Pedal edema
Pulse 72/min. good volume
BP ( left lateral position left arm) normal < 140/90 synchronized with other side
SYSTEMIC EXAMINATION
a) Chest : breast – primary areola
Secondary areola
Nipple everted
Montegary tubercles
Any palpable mass (fibroadenoma)
b) Respiratory system- normal b/l vesicular breathing
c) Heart- s1 s2 normal and apex in 4th intercostal space
d) Abdomen
Done with pt lying dorsally with legs flexed and after evacuating bladder and standing right
side
1. Inspection : linea nigra
Striae gravidarum
Striae albicentes
Distended
Umbilicus location
Skin normal – shiny with engorged veins (hydramnios)
Scar mark of prevous surgery
Lesions of scabies
2. Palpation : symphysiofundal height by ulnar border of left hand above downwards.
Pregnancy uterus
12-14wks =just palpable
16wks= midpoint of pubic symphysis and lower border of umbilicus
20wks= lower border of umbilicus
22wks = midpoint of umbilicus
24 wks= upper border of umbilicus
28 wks = junction of upper 2/3rd and lower 1/3rd ( xiphisternum to upper border of
umbilicus)
32wks = junction of upper 1/3rd and lower 2/3rd
36wks= xiphisternum
Term = 34wks with flanks full
GRIPS
1) Fundal grip ( pt face) : soft broad irregular ( breech)
Smooth hard globular (head)
2) Lateral grips (pt face) : smooth curve (back) usually on left side
Irregular knobby parts (limbs) usually on right side
3) Pawlik grip (pt face) : presenting part free/fixed
4) Pelvic grip ( pt feet) : breech/ cephalic , free/fixed, flexed/deflexed
Cephalic :occiput towards back, Sinciput towards limbs : if this is higher than occiput
than flexed head
FHS : spino umbilical line 120-160/min. ( avg 140/min.)
Height : increase by 1cm/week after 16wks increase by 1inch/wk after 30wks
Girth : increase by 1inch/wk after 30wks ( at term 100cm)
Till 36wks no. of wks of pregnancy= ht in cm
If <2cm difference = IUGR
Weight of baby ( johnson’s formula):
If head above ‘0’ station i.e. ischial spine = height of uterus in cm - 12×155= wt in grams
If head below ‘0’ station i.e. ischial spine = height of uterus in cm - 11×155= wt in grams
Eg. Ht of uterus above symohysis 32cm and station -2
Thus wt of baby= (32-12)× 155= 3100gm
P/V in first trimester only if bleeding
Uterus size
6wks=hen’s egg
8wks = cricket ball
12wks= fetal head
p/v after 37 wks – pelvis normal /contracted
p/v in labour/ leaking pv
Puerperal examination: look for LSCS wound , episiotomy wound
after delivery uterus around umbilicus within 24 hrs. decreases bt 1.25cm/day
by 2 wks in vaginal delivery and by 3 wks in LSCS uterus becomes non palpable (becomes pelvic
organ)
look for lochia on pad ( pus in centre = puerperal pyrexia)
legs for DVT
Breasts for breast feeding
Diagnosis : Seema age ____yrs old G P A with ___wks pregnancy with __________ presentation
with ______
Routine investigations of pregnancy:
Hb
Urine complete examination
ABORh
STS
HbsAg
HIV
HCV
T3T4TSH
Bld sugar
USG uterus -FWB, CMF,Liquor ,placenta
