ANC CASE PRESENTATION

GROUP 7
1. JAYAVARDHINI S – 52
2. JEEVANANTHAN B – 53
3. JEYANTH K – 56
4. K MONIKAA – 57
5. K S SURYA – 58
 PATIENT DETAILS
 Name : Mrs Ayesha begam
 Age : 24 yrs
 Sex : Female
 Religion : Muslim
 Education : Bsc discontinued
 Occupation : Homemaker
 Husband name : Mr Sayedd
 Address : No 24, hospital street mettupalayam Puducherry 9
 Blood group : o positive
 FAMILY PROFILE
FAMILY TYPE : THREE GENERATION FAMILY
NO OF ELIGIBLE COUPLE : 1

S. NO NAME RELATION TO HEAD OF THE FAMILY AGE/SEX EDUCATION MARITAL STATUS INCOME MEDICA
L
ILLNESS

1 ZAIRABI SELF 69/F 3RD PASS WIDOW 2,500 HTN,

DM
2 SAYEDD SON 38/M 10TH PASS MARRIED 20,000 NIL

3 AYESHA DAUGHTER IN LAW 24/F BSc MARRIED NIL NIL

4 TAUFICA GRAND DAUGHTER 6/F 1STD NIL NIL NIL

 Family tree
Due to cardiac arrest.

Head of the family

Daughter in
law
son

Grand daughter
 Nearest health facility
 Nearest health care facility : PHC mettupalayam
 Time taken to reach : 5 mins by walk
 Preferred health care facility for ANC : PHC mettupalayam
 Reason for preference : All facilities for antenatal care are
available and nearby to approach.
 Preferred facility for delivery : Indira Gandhi medical
college and research institute
 Reason for preference : better treatment and patient
care.
 OBSTETRIC HISTORY
 The obstetric score for the patient G-2 P-1 L-1 A-0
 LMP 13.04.23
 EDD 20.01.24
 Period of gestation – 13 weeks + 5 days
 CHIEF COMPLAINTS

 History of amenorrhea for the past 3 months.

 ANTENATAL HISTORY
FIRST TRIMESTER
 Conception was spontaneous
 Pregnancy was confirmed after 50 days of amenorrhea by urine pregnancy
test at PHC mettupalayam
 No H/O excessive vomiting
 No H/O bleeding per vagina
 No H/O exposure to radiation
 H/O administration of 2 dosses of Td vaccination at 2 nd month with a gap of
4 weeks between each dose [1st dose at 7/6/23 , 2nd dose at 12/7/23]
 No of antenatal visit -1 [ 12/7/23]
 Dating scan was done and it was normal.
 Folic acid supplementation taking .
 SECOND TRIMESTER
 She has been immunized with two does of Td injection.
 Quickening : not felt
 IFA tablets supplementation taking regularly
 Anomaly scan : not done
 No other investigations done
 No H/O blurring of vision , convulsions , increased
frequency of micturition
 No H/O fatigue and weakness
 No H/O epigastric pain, pedal edema , headache
 INVESTIGATIONS DONE

 Hemoglobin level – [11.6 mg/dl on 7/6/23] [10.2 mg/dl on

12/7/23]
 Urine albumin and urine sugar –nil
 HIV screening and syphilis test – non reactive
 HBsAg- negative
 Blood sugar level – normal
 Thyroid test – normal
 PAST OBSTETRIC HISTORY
 she was a booked case.
 She had given birth to a female child.
 It was a term delivery.
 Name : TAUFICA
 Age : 6 yrs
 Birth weight : 3.5 kg
 Place of birth : Indira Gandhi medical college and research institute Pondicherry.
 No H/O complications during antenatal period.
 Mode of delivery : spontaneous vaginal delivery .
 The baby cried immediately after delivery and breast feed was started within 30
mins . Exclusively breast feed upto 9 months of age.
 No H/O blood transfusion.
 Healthy at present .
 MENSTRUAL HISTORY
 Age at menarche 14 years
 Last menstrual period 13/4/23
 Menstrual cycle : regular, once in 28 days, lasting for 3 to 4
days, with a moderate flow.
 No H/O associated clots or dysmenorrhea.
 MARITAL HISTORY
 Age at marriage : 18 years
 Non consanguineous marriage .
 Age during first pregnancy : 18 years
 Age during second pregnancy : 24 years
 They had not been using contraception methods.
 PAST HISTORY
 No H/O previous hospitalization
 No H/O surgeries in past.
 No H/O hypertension, diabetic, tuberculosis etc.
 No H/O blood transfusion
 PERSONAL HISTORY
 Adequate sleep
 She does the routine household activity .
 No H/O addictions
 No H/O drug allergies .
 Regular bowel and bladder habits.
 No H/O any medications.
 Good personal hygiene.
 FAMILY HISTORY
 Type of family – Three generation family
 No of family members – 4
 No H/O twin pregnancy
 There is a H/O HTN , DM among her family member [ZAIRABI]
69 years old.
 No H/O any blood disorder , congenital anomalies among her
family members
 No H/O of TB or any other infections among family members .
 SOCIO ECONOMIC HISTORY
 Total family income per month – RS 22,500
 No of family members – 4
 Earning members of the family – 2
 Per capita income – RS 5,625
 Socio economic class – II [ upper middle ] as per modified
classification BG PRASAD scale may 2022 .
 Colour of ration card : yellow
 Debts/loan : no
 Health insurance : yes
 House – own house
SOCIO ECONOMIC STATUS
 NUTRITIONAL HISTORY
 Mixed diet
 Staple food – rice
 Frequency of food – three times a day
 Non vegetarian food taken 1-2 days per week
 Purchase of fruits and vegetables : daily basis and when needed .
 Hygienic cooking practice
 No H/O skipping food
 No food faddism or any food taboo
 DIET HISTORY
 Type of salt intake : Iodised salt
 Total monthly salt intake : 1 kg /month/4 persons
 250 gm /30 days
 8.3 gm /person /day
 Oil consumption : groundnut oil/palm oil
 Oil consumption : 1L /month
 1000ml/30days/4 persons
 8.3 ml /person/day.
 QUALITATIVE NUTRITIONAL HISTORY
24 HR RECALL METHOD

TIMING FOOD CONSUMED CALORIES PROTIEN

BREAKFAST DOSA [3] / SAMBAR 504+130 KCAL 11.7 + 7 g

SNACK POMEGRANATE [1/2] 117 KCAL 24 g

LUNCH RICE [1CUP] / FISH 206 + 307 KCAL 4.2 + 36 g

CURRY [1 SERVING ]
SNACK APPLE [1 ] 95 KCAL 0.5 g

DINNER RICE [ 1 CUP ] / FISH 206 + 307 KCAL 4.2 + 36 g

CURRY [1 SERVING ]
TOTAL 1872 KCAL 102 g
 DIET INTERPRETATION
RECOMMENDED OBSERVED COMMENT

CALORIES 2000 + 350 KCAL 1872 KCAL CALORIE DEFICIT

2350 KCAL [21%]

PROTIEN 50 + 22 G 102 G ADEQUATE PROTIENS

72G
 ENVIRONMENTAL HISTORY

 Road : clean and proper road facilities

 Street lights present
 Common dustbin present
 Stray dogs present
 Breeding places for mosquito present
 INTERNAL ENVIRONMENT

 Type of house : pucca

 No of living room : 3
 No of persons per room : 2
 Overcrowding is not present
 Adequate lighting and ventilation
 Separate kitchen with window and smoke outlet outside
 Type of fuel used – LPG
 No indoor air pollution
 Adequate cleanliness
 Source of water : borewell
 Collection of water from tap and stored in clean and closed
vessel
 She uses boiling as method of purification
 Dustbin present inside the house and closed
 Waste disposal : collected by municipality daily.
 Latrine present inside the house
 No pet animals in the house
 PSYCHOSOCIAL HISTORY
 The family is supportive
 She is accompanied by her husband to the hospital.
 No disputes within the family
 Has a cordial relationship with the neighbours
 They participate in social functions .
 The mother and family members have no baby gender
preference
 Husband is supportive and caring
 KNOWLEDGE ATTITUDE AND PRACTICE
KNOWLEDGE
She is aware of complications in
pregnancy
Has knowledge about contraception
Aware of gender prevalence
Has knowledge about IFA and ca
tablets
Has knowledge about regular check
up
Aware about immunization practices
ATTITUDE
She is willing to visit the hospital in
case of any complications
Willing to do tubectomy after the
delivery of second child
Has no gender preference
Willing to take iron and calcium
tablets
Willing to come for regular check up
Willing to get immunized with Td
PRACTICE
She visits the hospital when
necessary
Planning to do tubectomy after
delivery
Follow no gender preferences
Has been taking iron tablets
Visit hospital for regular check up
Immunized with two doses of Td
 EXAMINATION
 The subject was conscious, cooperative and well oriented to
time, place and person .
 Height : 155.5 cm

 Weight : 58 kg [present]
 Pallor : absent
 Icterus : absent
 Cyanosis : absent
 Clubbing : absent
 Lymphadenopathy : absent
 Edema : absent
 Thyroid gland examination : normal
 Breast examination : normal
 Spine and gait : normal
VITAL SIGNS
 Pulse rate : 82 beats /min regular rhythm, normal volume,
and character , no radio-radial delay, no radio-femoral
delay .
 Blood pressure : 110/70 mm of Hg .
 Respiratory rate : 17 breaths /min .
 Temperature : afebrile
 SYSTEMIC EXAMINATION

CVS EXAMINATION
S1 and S2 are heard normally.
No murmur heard.
RS EXAMINATION
Normal vesicular breath sounds are heard.
No added sounds
CNS EXAMINATION
No focal neurological deficit.
 ABDOMEN EXAMINATION
INSPECTION
 No distension of abdomen
 Umbilicus at centre
 Linea nigra is seen faintly.
 Stria gravidarum : absent
 Scars, sinuses and dilated veins are absent .
 No visible pulsations
 CLINICAL DIAGNOSIS

 Mrs Ayesha 24 years old 2nd gravida in 2nd trimester from

mettupalayam with obstetric score of G2 P1 L1 A0 , LMP
13/4/23 and EDD 20/1/24 with a period of gestation of 13
weeks. Registered at PHC mettupalayam and immunized for
Td, taking IFA tablets .
 FAMILY DIAGNOSIS
 A three generation family consisting of 4 members with 1
eligible couples, living in a pucca house belonging to class
II[ upper middle ] socio economic details according to
modified BG PRASAD scale 2022 , with a pregnant woman at
12 weeks of gestation . comorbidities among her family
member [ Zairabi ] is HTN , DM and she is taking regular
tablets and medications . She has a supportive family
members and neighbours.
 MANAGEMENT
 Advised to take nutritious food.
 Advised to take iron rich food .
 Told her the importance of IFA supplementation and immunization.
 Advised to give colostrum
 Advised her to exclusively breast feed the child for 6 months and told
her importance of it
Family level
 Family must provide mental support.
Community level
 Avail Anganwadi services.
 Importance of IFA consumption