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ANTENATAL ASSESSMENT Form 13

This document contains an antenatal assessment of a 23-year-old pregnant woman. The assessment includes her medical history, family history, obstetric history, examination findings, investigations, treatment plan, and health education provided. She is a G1P0L0A0 patient at 24 weeks and 8 days gestation with normal vital signs and examination findings. Her hemoglobin is 12gm/dl and she is Rh positive with no other abnormalities on screening tests. She is advised to follow up regularly and take calcium and iron supplements as prescribed.

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Kaku Manisha
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2K views

ANTENATAL ASSESSMENT Form 13

This document contains an antenatal assessment of a 23-year-old pregnant woman. The assessment includes her medical history, family history, obstetric history, examination findings, investigations, treatment plan, and health education provided. She is a G1P0L0A0 patient at 24 weeks and 8 days gestation with normal vital signs and examination findings. Her hemoglobin is 12gm/dl and she is Rh positive with no other abnormalities on screening tests. She is advised to follow up regularly and take calcium and iron supplements as prescribed.

Uploaded by

Kaku Manisha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ANTENATAL ASSESSMENT - 13

Name:- Meenaba Pradeepsinh Jadeja Age:- 23 years


Registration No:- 456788 Date:- 5/8/21
L.M.P.:- 1/2/21 E.D.D:- 8/11/21
Obstetrical Score: G1P0L0A0

 MEDICAL HISTORY:
Anaemia: Absent Heart Disease:- Absent
Pulmonary Disease:- Bronchial Asthuma Allergy:- Absent
Other:- Absent *H/o: RTI/STI/HIV:- Absent

 FAMILY HISTORY:
Type of Family: Single..................... No. of Persons: .......................
Joint: Yes No. of Persons: 5

 PERSONAL HISTORY:
Diet: Vegetarian Addiction: Absent
Likes:Pulav rice, Dal fry Dislike: Bringer
Bowel: Regular Bladder: Regular
Tetanus Immunization: 1st dose of Inj. T.T taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 22000
Education: Husband: 10th pass Wife: 7th pass
Occupation: Husband: Business Wife: Housewife
 MENSTRUAL HISTORY:
Menarchy: At 13 years of age Duration: 5 days
Interval: 28 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 21 year Years Married: 2 years
Consanguineous: no

 PAST OBSTETRICAL HISTORY:

Sr. Year Full Pre Abortion Type Baby Re


No. term term of Sex Alive Stillborn Weight mark
Delive
ry

Nil

 GENERAL EXAMINATION:
General Condition: Normal Temperature: 96.5 F
Pulse: 80/min Respiration: 18/min
Blood Pressure: 110/80 mmhg Other Features: No any
Pallor: Absent 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 no any symptoms related
to nervous system
2. Cardiovascular System: S1 S2 heard with the blood pressure of
110/80mmhg
3. Respiratory System: The respiratory rate are 18/min with normal lung
sounds
4. Gastrointestinal System: The mother has normal bowel sounds and no
any symptoms related to Gastrointestinal system
5. Reproductive System: The size of uterus is increased at 24cm with the
abdominal girth of 55cm. The uterus is soft
6. Musculo-skeletal System: The patient has normal tendon reflexes and
muscle strength.
7. Integumentary System: The presence of chloasma and linia nigra

 OBSTETRIC EXAMINATION:
Date Weight B.P. Urine Fundal Abdom Uterine Present FHR Posit Re
mmHg Protein Gluc height inal Size ation (bpm) ion mar
ose (cm) Size (wks) k
(cm)
9/8/2 62kg 110/80 Absent Abse 24cm 55cm 24 - 110bp -
1 mmhg nt week m
and 8
days
 INVESTIGATIONS:
Blood group: B Positive Rh: Positive
Hemoglobin: 12gm/dl VDRL: Negative
HIV: Negative Others: No any

 TREATMENT GIVEN:
The following treatment is given:
 Calcium 500mg 2BD
 Iron 40mg OD

 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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