ANTENATAL ASSESSMENT - 1

Name:- Binaba Vijaysinh ker Age:- 25 year

Registration No:- 60623 Date:- 2/8/21
L.M.P.:- 3/2/21 E.D.D:- 10/11/21
Obstetrical Score: G1P0L0A0

 MEDICAL HISTORY:
Anaemia:-Present Heart Disease:- No
Pulmonary Disease:- No Allergy:- No any
Other:- No *H/o: RTI/STI/HIV:- No

 FAMILY HISTORY:
Type of Family: Nuclear: yes No. of Persons: Four
Joint: .............. No. of Persons: ..............

 PERSONAL HISTORY:
Diet: Vegetarian Addiction: No any
Likes: Dal, Rice, Roti Dislikes: Eggs
Bowel: Regular Bladder: Regular
Tetanus Immunization: Two doses of Inj. T.T taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 10000
Education: Husband: 12th pass Wife: 12th pass
Occupation: Husband: Business Wife: Housewife
  MENSTRUAL HISTORY:
Menarchy: At 12 years of age Duration: 5 days
Interval: 26 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 22 years Years Married: 3 years
Consanguineous: no

 PAST OBSTETRICAL HISTORY:

Sr. Year Full Pre Abortio Type Baby Re

No. term term n of mark
Delive Sex Alive Stillbor Weight
ry n

Nil

 GENERAL EXAMINATION:
General Condition: Normal
Pulse: 82/min
Blood Pressure: 120/ 70 mmhg
Pallor: Present
Icterus: Absent
Breasts: Right: Primary areola &
Montagomerry tubercles present
Nipples: Right: Everted
Temperature: 98.4 F
Respiration: 16/min
Other Features:
Oedema: Absent
Lymphadenopathy: Absent
Left: Primary areola &
Montagomerry tubercles present
Left: Everted
  SYSTEMIC EXAMINATION:
1. Nervous System: Patient is conscious and No any symptoms related
to nervous system
2. Cardiovascular System: S1 & S2 present with Blood Pressure of
120/70mmg. The patient has complain of fatigue. Pallor seen
3. Respiratory System: Patient has normal lung sounds and the
respiratory rate of 16/min
4. Gastrointestinal System: Patient has regular bowel movements
5. Reproductive System: The size of uterus is increased. Fundal height is
24cm, abdominal girth is 55cm. Uterus is soft
6. Musculo-skeletal System: Patient have complain of lower back pain
with leg cramps
7. Integumentary System: The skin is pigmented with presence of linia
nigra and mask of chloasma

 OBSTETRIC EXAMINATION:

Date Weig B.P. Urine Fundal Abdom Uterin Present FHR Posi Rema
ht mmHg Protein Gluco height inal e ation (bpm tion rk
se (cm) Size Size )
(cm) (wks)
2/8/2 62 kg 120/7 Absent Abse 28cm 55cm 28 Cephali 124 ROA No
1 0mmh nt weeks c bpm any
g

 INVESTIGATIONS:
 Blood group: A Positive Rh: Positive
Haemoglobin: 9 gm/dl VDRL: Negative
HIV: Positive Others: No any

 TREATMENT GIVEN:
The following treatment is given:
 Tab. Calcium 500mg BD Orally
 Tab. Iron 40mg BD Orally

 HEALTH EDUCATION:
I have given health education on following points:
 Regular follow up for antenatal check-up
 Regular administration of given drugs
 Care during antenatal period
 Dietary requirements during antenatal periods and
maintenance of GI symptoms and anemia
 Antenatal exercise