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ANTENATAL ASSESSMENT Form 11

This document contains an antenatal assessment of a 23-year-old pregnant woman. She is in her 36th week of pregnancy, with no significant medical or obstetric history. On examination, she has pallor and edema. Lab results show her hemoglobin is low. She is given calcium, iron supplements and health education on antenatal care.

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Kaku Manisha
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1K views4 pages

ANTENATAL ASSESSMENT Form 11

This document contains an antenatal assessment of a 23-year-old pregnant woman. She is in her 36th week of pregnancy, with no significant medical or obstetric history. On examination, she has pallor and edema. Lab results show her hemoglobin is low. She is given calcium, iron supplements and health education on 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.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Antenatal Summary: Provides a brief overview of the patient's personal, medical, and socio-economic details relevant to the antenatal assessment.
  • Medical & Family History: Details the patient's medical history including anaemia, prior diseases, and family medical background.
  • General & Systemic Examination: Covers the patient's menstrual, marital, and past obstetrical history along with a general physical exam.
  • Investigations & Treatment: Lists medical investigations conducted alongside treatments given and health education advice provided.

ANTENATAL ASSESSMENT -11

Name:- Manjuben Bhaveshbhai Maniar Age:- 23 year


Registration No:- 67583 Date:- 4/8/21
L.M.P.:- 22/12/20 E.D.D:- 29/9/21
Obstetrical Score: G1P0L0A0

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

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

 PERSONAL HISTORY:
Diet: Vegetarian Addiction: No any
Likes: Dal, Rice, Mix sbji Dislikes: Sienach
Bowel: Irregular Bladder: Frequency of
Urination is increased
Tetanus Immunization: Two doses of Inj. T.T Taken

 SOCIOECONOMIC BACKGROUND:
Religion: Hindu Family Income: 20000
Education: Husband: B.Com Wife: 10th pass
Occupation: Husband: Job Wife: Housewife
 MENSTRUAL HISTORY:
Menarchy: At 12 years of age Duration: 5 days
Interval: 30 days Flow: Regular

 MARITAL HISTORY:
Age of marriage: 20 year Years Married: Three
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: 98.4 F
Pulse: 78/min Respiration: 18/min
Blood Pressure: 110/70mmhg Other Features: No any
Pallor: Present Oedema: Present
Icterus: Absent Lymphadenopathy: Absent
Breasts: Right: Secondary areola & Left: Secondary areola &
Montagomery tubercles seen Montagomery tubercles seen
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
110/70mmhg
3. Respiratory System: The respiratory rate are 18/min with normal lung
sounds. The mother has complain of mild difficulty in breathing
4. Gastrointestinal System: The bowel sounds are decreased and mother has
complain of mild constipation
5. Reproductive System: The size of uterus increased at 36cm with the
abdominal girth of 60cm. The uterus is soft
6. Musculo-skeletal System: The patient has complain of lower back pain
and swelling
7. Integumentary System: The skin is hyperpigmanted with 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)
4/8/2 74kg 110/70 Absent Abse 36cm 60cm 36 Cephali 120b RO
1 mmhg nt weeks c pm A
 INVESTIGATIONS:
Blood group: AB Positive Rh: Negative
Haemoglobin: 8.5gm/dl VDRL: Negative
HIV: Negative Others: No any

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

 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

ANTENATAL ASSESSMENT -11 Name:- Manjuben Bhaveshbhai Maniar Age:- 23 year Registration No:- 67583 Date:- 4/8/21 L.
 MENSTRUAL HISTORY: Menarchy: At 12 years of age Duration: 5 days Interval: 30 days Flow: Regular  MARITAL HISTORY: Age o
 SYSTEMIC EXAMINATION: 1. Nervous System: The mother is conscious and no any symptoms related to nervous system 2. Cardiova
 INVESTIGATIONS: Blood group: AB Positive Rh: Negative Haemoglobin: 8.5gm/dl VDRL: Negative HIV: Negative Others: No any 

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