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Antenatal Assessment Form 9

The document contains an antenatal assessment of a 26-year-old pregnant woman, Minaxiben Jatinbhai Vadgama, noting her medical history, obstetric history including one previous full term delivery and one abortion, physical examination findings of her current pregnancy including fetal position and heart rate, lab results, treatment plan of calcium, iron, and ibuprofen supplements, and the health education provided regarding antenatal care.

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Kaku Manisha
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2K views

Antenatal Assessment Form 9

The document contains an antenatal assessment of a 26-year-old pregnant woman, Minaxiben Jatinbhai Vadgama, noting her medical history, obstetric history including one previous full term delivery and one abortion, physical examination findings of her current pregnancy including fetal position and heart rate, lab results, treatment plan of calcium, iron, and ibuprofen supplements, and the health education provided regarding antenatal care.

Uploaded by

Kaku Manisha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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ANTENATAL ASSESSMENT -9

Name:- Minaxiben Jatinbhai Vadgama Age:- 26 years


Registration No:- 657453 Date:- 6/8/21
L.M.P.:- 6/12/20 E.D.D:- 13/9/21
Obstetrical Score: G3 P1 L1 A1
 MEDICAL HISTORY:
Anaemia: Present Heart Disease:- Absent
Pulmonary Disease:- Absent Allergy:-Absent
Other:- No any *H/o: RTI/STI/HIV:- No

 FAMILY HISTORY:
Type of Family: Single: Yes No. of Persons: Four
Joint........................... No. of Persons:...........................

 PERSONAL HISTORY:
Diet: Vagitarian Addiction: No any
Likes: Handwork Dislikes: -
Bowel: Irregular Bladder: Frequency of
Micturation is increased
Tetanus Immunization: Taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 20000
Education: Husband: B.Com Wife: 12th pass
Occupation: Husband: Business Wife: Housewife

 MENSTRUAL HISTORY:
Menarchy: 14 Duration: 5 days
Interval: 30 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 20 year Years Married: 6
years
Consanguineous: no

 PAST OBSTETRICAL HISTORY:

Sr. Year Full Pre Abortio Type Baby Re


No. term term n of Sex Alive Stillborn Weight mark
Delive
ry
1 2017 yes FTND Mal Yes 3.8kg
e
2 2019 Yes

 GENERAL EXAMINATION:
General Condition: Normal Temperature: 98.7 F
Pulse: 86/min Respiration: 22/min
Blood Pressure: 130/80mmhg Other Features: No
any
Pallor: Present Oedema: Absent
Icterus: Absent Lymphadenopathy: Absent
Breasts: Right: Enlarged Left: Enlarged
Nipples: Right: Everted Left: Everted

 SYSTEMIC EXAMINATION:
1. Nervous System: The mother is conscious and there no any
symptoms related to nervous system
2. Cardiovascular System: S1 S2 heard with the blood pressure of
130/80mmhg
3. Respiratory System: The respiratory rate are 22min with normal lung
sounds. The mother has complain of dyspnea
4. Gastrointestinal System: The patient has decreased bowel sounds
with complain of mild constipation
5. Reproductive System: The uterus is enlarged at the size of 34cm and
abdominal girth is 70cm. The mother has complain of lower
abdominal pain. The uterus is soft
6. Musculo-skeletal System: The mother has lower back pain with ankle
edema
7. Integumentary System: The skin is hyperpigmanted with the
presence of chloasma and linia nigra

 OBSTETRIC EXAMINATION:
Date Weight B.P. Urine Fundal Abdom Uterin Presen FHR Posi Re
mmHg Protei Gluc height inal e tation (bpm tion mar
n ose (cm) Size Size ) k
(cm) (wks)
6/8/ 80kg 130/8 Absent Abse 34cm 70cm 34 Breech 114b LOP
21 0mmh nt weeks pm
g

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

 TREATMENT GIVEN:
The following treatment is given:
 Calcium 500mg 2BD orally
 Iron 40mg BD orally
 Ibuprofen 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
 Antenatal exercise

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