Professional Documents
Culture Documents
Case Write Up 1 ANC
Case Write Up 1 ANC
Demographics:
Name: KodezaSultan
MRN#: 0000
Age: 34 Years Old
Gender: Female
Nationality: Bangladesh
Occupation: Housewife
Marital status: married for 6 years
Gravidity and parity: G2 P0
LMP:22/7/2016
EDD:29/4/2017
Gestational age: 14+1 wks
Blood group: ordered
Subjective:
CC: patient came for her booking visit to antenatal clinic.
HPI:
34 years old female presented to PHC for first time during her pregnancy
(booking visit) to follow her pregnancy. She also complaining of fever and dry
cough for the past 4 days.
Her condition is improving and she didnt take any medicine to relieve her
symptoms and just take rest. Nothing makes it worse.
There are no headaches, dizziness, chest pain, flank or back pain, no change
in bowel motion or change in the urination pattern and no burning sensation
while urination was note.
No hx of recent travel, contact with sick people or STDs.
ICE
Parents Ideas: Patient knows that she is pregnant.
Patients Concerns: She wants to know if there is risk of miscarriage in
her pregnancy.
Patients Expectation: She wants to get the proper management and
care during her pregnancy.
This was a planned pregnancy and she knew about it by a positive urine
pregnancy test at home.
Obstetric history:
She had one previous pregnancy which is ended by abortion during 3rd month
of her pregnancy at home and she didnt do D &C since it was complete
abortion and confirmed in hospital.
Menstrual history:
Menses are regular occurring every 28 days for 7 days of average flow without
signs of menorrhagia and dysmenorrheal.
Gynecological history:
Contraceptive history: she denied use of any contraception method but she
said she avoided pregnancy naturally by her own (natural contraception).
Drugs History:
Drugs: none
Allergies: Penicillin allergy.
Social History: she is a housewife, married and lives with spouse and spouse
family.
She eats home cooked food mainly, doesnt smoke, drink alcohol, or consume
recreational drugs and exercise occasionally.
Objective:
Examination:
General: she looks well, alert, oriented, not in acute distress, sitting on bed
comfortably.
Vitals:
HEENT:
Nose: normal, no obstruction.
Throat: Normal
LN: not enlarged
Chest Examination:
Chest is symmetrical, clear to auscultation. Normal breathing sounds and air
entry.
Plan:
Management Plan and counseling:
Patient education was done and advised to take folic acid, vitamin D,
calcium supplements during her pregnancy and safety netting regarding
danger signs of pregnancy ( like vaginal bleeding, decrease fetal
movement, leakage of water, dizziness, eye problem and edema was
given).
Medications:
Ethics:
No Ethical issues or conflicts were involved in this cas