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Identification Data

The document provides identification and medical history information for a 20 year old pregnant patient. It details her chief complaints, examination findings, obstetric history, and physical assessment. The document contains a large amount of information collected for the patient's medical record.

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22 views8 pages

Identification Data

The document provides identification and medical history information for a 20 year old pregnant patient. It details her chief complaints, examination findings, obstetric history, and physical assessment. The document contains a large amount of information collected for the patient's medical record.

Uploaded by

anu aa
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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IDENTIFICATION DATA

Name of the patient - Mrs Subha zehra

Age : 20 years

Husband's name -Mr Mohd Yaseen

L.P.D. no-

Ward no. /bed no:- labor ward. General room/bed no-

Date of admission.

Educational status

Graduated

Occupation of mother : currently not working

Occupation of Husband Private Job

Religion

Diagnosis : Primigravida at 38 weeks 3 days with Rh negative pregnancy

Date of delivery -

Duration of marriage-

Address B-188, Mohan Baba Nagar, Badarpur, New Delhi.

Doctor incharge-

Date of care started-

Date of discharge

ADMISSION HISTORY-
CHIEF COMPLAINTS ON ADMISSION-
Mrs Subra Zehra w/o Mr Mohd Yaseen 20 year female Primigravida 38 weeks of
period of gestation with Rh-ve pregnancy admitted on 22/9/19 at 11:35 pm with
complaints of-

 Amenorrhea since 9 months


 Pain in abdomen since 3 Hour.
 Bleeding per vagina since morning

ON EXAMINATION
 General condition is fair.
 Patient is afebrile.
 Oedema absent.
 Pallor present.
 Pulse: 102/min.
 BP: 120/80mm/hg.
 Chest/CVS-NAD.
 Per Abdomen- Cephalic presentation, ROA, FHR-140/mt with Doppler. Mild
uterine
 contraction present.
 Vaginal Examination: OS admitting 1 finger cervix uneffaced, vertex at brim.
Pelvic.
 Adequate, membrane ruptured.
HISTORY OF PRESENT PREGNANCY
 Mrs subha zehra w.o mohd yaseen has spontaneous conception and
detected by UPT then confirmed by USG
 Trimester 1
 All antenatal visit and check was done in holy family hospital
 Tab Folic Acid 5 mg treatment taken.
 No history of BPV present, hospitalisation, radiation exposure, drug
exposure
 Having c/o of nausea and vomiting
 Trimester 2
 Nausea vomiting continued.
 Quickening felt at 5 months.
 Received 2 doses of TT injection,
 Regular intake of Iron and calcium supplementation.
 No history of raised BP, pedal edema, blurred vision, headache, epigastric
pain.
 No history of BPV and LPV present.
 Increased blood sugar level was there which get manages automatically by
diabetic diet.
 Took Anti D
 Trimester 3
 Iron and calcium supplementation continued.
 No history of BPV, seizures.
 Having complain of fatigue.
OBSTETRICAL HISTORY

 ✔ Primigravida G(1)P(0)L(0)A(0)
 ✔ Period of gestation in week is 38 weeks plus 3 days.
PAST MENSTURAL HISTORY
 LMP: 17/12/18
 EDD: 24/9/19 by naegele's formula
 Cycle: irregular due to PCOD later after treatment it was 4-5 days/30days
 Dysmenorrhoea: absent
PAST MEDICAL HISTORY
 No past medical history
 SURGICAL HISTORY
 No history of any past surgery
HISTORY OF BLOOD TRANSFUSION
No history of blood transfusion.

FAMILY HISTORY
Living in joint family
There are 8 members in her house.
No history of congenital anomalies present.
No significant family history of any hereditary illness in family. No history of
chronic illness and mental illness present

PERSONAL HISTORY

she is non vegetarian.


Non-smoker, non-alcoholic, non-addicted to any drug.
Personal hygiene is self-maintained.
Bowel and bladder movements are normal.
Normal sleep pattern (7-8hrs/day)

SOCIO-ECONOMIC DATA

Type of family- nuclear.

Number of family member: 8


House: lives in rented house in Badarpur, Delhi. With proper ventilation
Number of room in house is 3 with 2 wash rooms and 1 kitchen
Electricity: available
Bathroom and toilet facility: both are separately present at their home,
Drainage: drainage system is closed.
They discard their waste properly in MCD garbage vans.
➤ Mrs Subha is homemaker and her husband is having private job with
salary of rupees 40000/- There is no financial crisis.
PHYSICAL ASSESSMENT
General assessment-

Height-160cm.
Weight-64.7 kg
Posture-normal
Nourishment- well nourished
Grooming- well groomed

Vital signs

Temperature: 97.2 F
Pulse-86/mt
Respiration rate-22beats/mt
Blood pressure- 110/70mm/Hg
Spo2-97% in room air

Head to toe examination


Hair is evenly distributed on head
Scalp is free of pediculosis no presence of dandruff over the scalp.
Head of the patient is round and symmetrical in shape
Eyebrow: eyebrow hairs are evenly distributed the client eyebrows are
symmetrically distributed and
Eyelashes: cyelashes appears to be equally distributed and black in color.
Conjunctiva appear pink in color.
Sclera is transparent and shinny.
Pupils are black and equal in size they are equally reactive to light. No
discharge present from eyes.
External ear - the auricles are symmetrical and has same colour with the
facial skin the auricles are aligned with outer canthus of the eye when
palpating for texture the auricles are mobile firm and non-tender.
 Tympanic membrane- there is no presence of perforation or
discharge. Hearing sense in present
 Nose appeared symmetrical straight and uniform in color.
 No discharge for nose
❖ Mucous membranes:-
 The mucous membrane is pink in color but appeared dry
 The nasal septum patient has straight nasal septum no deviation is
found.

Mouth
 Lips the lips of the mother is pink.
 Gums absent of bleeding and gingivitis.
 Teeth clean and white and 32 in number
 Tongue the tongue of the client is centrally positioned and pink in
colour
 Oral mucus is intact.
 Lymph nodes of the client are not palpable
Patient is having endotracheal tube and airway going through mouth.

 Thyroid glands are not enlarged.

 Integumentary
 Color-wheatish
 Hydration of skin- well hydrated
 Turgor-normal
 Edema- not present.
 Cyanosis-absent
Pallor present-
which represent moderate anemia.
Thorax and lungs
With is inspiration and expiration chest rise in seen.
Breath sounds are clear
In chest(heart) S1 and S2 sounds are clearly heard.
Capillary refill time is <2 sec.

Chest deformity absent.

Breast;-
On inspection
➤Bilateral Breast are symmetrical in shape and size.
➤ Nipples are erected
Secondary areola is present.
Montgomery tubercles are clearly visible. No signs of redness and
swelling seen.
On palpation
No hard mass or nodules are felt.
Breast engorgement is not seen.
Abdomen

Colostrum can be squeezed out easily.

On inspection:

✓ Appropriate to gestational age.-

Spherical in shape.

Linea nigra present

✓ Straie gravidarum is present.-

On palpation
✓ Fundal grip- soft irregular nodular mass is palpable which represents fetus
buttocks.

✔ Lateral grip- On right side hard resistance structure is felt which represents
back of the fetus. On left side numerous small irregular mobile parts are felt
which represents fetal limbs

✔ Pawlik grip- mobile mass is felt. Which represent that head is not engaged.

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