PATIENT PROFILE

Name of patient Nisha

Husband’s name Lokesh

Age 27 years Religion

Hindu Occupation House wife

Education 10th

Address Shastri Nagar, Jaipur

Duration of marriage 6 years

Ward Labour Room

Date of admission 05.12.10 8 A.M

Registration No. 30343

Obstetrical score G1P0 A0 L

L.M.P. 02.03.2018

E.D.D. 09.12.2018

A. CHIEF COMPLAINTS :-
(i) Amenorrhoea from 9months

(ii)Having Labor pain since 4A.M

(iii) Back ache

B. HISTORY COLLECTION

(i) HISTORY OF PRESENT ILLNESS: - Patient was admitted on 05-12-2018 at

8.A.M. with complain of amenorrhoea from 9 months, pain in lower abdomen
since 4.A.M. (

ii) HISTORY OF PAST ILLNESS: - Medical History:- No H/o D/M, HTN, CAD and
T.

B. Surgical History – Not significant.

(III) FAMILY HISTORY: - No history of heretical and genetically disorder.

PERSONAL HISTORY: - Patient is vegetarian. No history of drug allergy or drug

addiction. No use of any type of substances use like smoking, drug abused and
alcohol etc.

FUNCTIONAL HISTORY: - Sleep pattern and appetite is normal.

MENSTRUL HISTORY: - Menstrul cycle is regular of 4-5 days. No intermenstrul

bleeding and no coital bleeding.
IDENTIFICATION DATA
Name: - B/o Lucky

Age & Sex: - 2 days/ female

Ward & unit: - Nursery-5

Bed no.: - 08

Reg. No. : - Pan 17-34580

Father’s Name: - Govind

Father’s occupation: - works in a factory

Mother’s occupation: - House Wife

Address: - Salarpur Noida G.B. Nagar, Uttar Pradesh

Date of Admission: - 21 March. 2019 at 11 AM

Income: - Rs. 5000-7000 per month

History of mother:

1. ADMISSION HISTORY: Patient admitted to the nursery 5 with the

complaining of respiratory distress.

2. PERSONAL HISTORY of mother: Lucky is married for 2yrs . They live in

their own house, with two room having separate kitchen and bathroom. She is a
non-vegetarian and has a normal bowel pattern. No habit of tobacco chewing or
smoking. She has normal sleep pattern of 5-6 hrs a day.
3. MEDICAL HISTORY: Patient have No history of T.B, HTN. No history of any
skin infection.

4. SURGICAL HISTORY: np surgical history..

5. FAMILY HISTORY: Saroj and her husband lives in a nuclear family in Delhi.
They have one daughter of 1yrs 2 month of age. Her husband is the only earning
member. Rest of the family members live in other place.

6. MENSTRUAL HISTORY: She attained her menarche at the age of 13 years.

She had regular cycle of 28-30 days and has a regular blood flow for 4-5 days,
associated with mild dysmenorrheal. No history of oligomenorrhea, menorrhagia,
etc.

7. OBSTETRICAL HISTORY: She is G₂P₁L₁. She have one girl child before 1yrs 2
month. Previous delivery was normal vaginal delivery in the hospital only . Child
was active and healthy.

8. HISTORY OF PRESENT PREGNANCY:

1st TRIMESTER- During her first trimester, she had mild nausea and vomiting in
morning that got relieved on its own. She was given 1st dose of T.T after one
month received the second dose of T.T.

2nd TRIMESTER- Her ultrasound was done on 19/11/2018. Findings were SLIUF
of 1