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    ANTENATAL ASSESSMENT Form 5

    Uploaded by

    Kaku Manisha
    This document contains an antenatal assessment of 29-year-old Kavitaben Mohanlal Patel. She is 29 weeks pregnant, with her last menstrual period on May 1st and an expected due date of October 12th. The assessment notes her medical, family, personal, and obstetric histories. On examination, she has anemia but is otherwise healthy. Lab tests show her blood group is A positive, Rh positive, with a hemoglobin level of 9.5 gm/dl and negative VDRL and HIV tests. She is prescribed calcium and iron supplements and given health education.

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    ANTENATAL ASSESSMENT Form 5

    Uploaded by

    Kaku Manisha
    318 views4 pages
    This document contains an antenatal assessment of 29-year-old Kavitaben Mohanlal Patel. She is 29 weeks pregnant, with her last menstrual period on May 1st and an expected due date of October 12th. The assessment notes her medical, family, personal, and obstetric histories. On examination, she has anemia but is otherwise healthy. Lab tests show her blood group is A positive, Rh positive, with a hemoglobin level of 9.5 gm/dl and negative VDRL and HIV tests. She is prescribed calcium and iron supplements and given health education.

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    ANTENATAL ASSESSMENT form 5

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    This document contains an antenatal assessment of 29-year-old Kavitaben Mohanlal Patel. She is 29 weeks pregnant, with her last menstrual period on May 1st and an expected due date of October 12th. The assessment notes her medical, family, personal, and obstetric histories. On examination, she has anemia but is otherwise healthy. Lab tests show her blood group is A positive, Rh positive, with a hemoglobin level of 9.5 gm/dl and negative VDRL and HIV tests. She is prescribed calcium and iron supplements and given health education.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    318 views4 pages

    ANTENATAL ASSESSMENT Form 5

    Uploaded by

    Kaku Manisha
    This document contains an antenatal assessment of 29-year-old Kavitaben Mohanlal Patel. She is 29 weeks pregnant, with her last menstrual period on May 1st and an expected due date of October 12th. The assessment notes her medical, family, personal, and obstetric histories. On examination, she has anemia but is otherwise healthy. Lab tests show her blood group is A positive, Rh positive, with a hemoglobin level of 9.5 gm/dl and negative VDRL and HIV tests. She is prescribed calcium and iron supplements and given health education.

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    ANTENATAL ASSESSMENT - 5

    Name:- Kavitaben Mohanlal Patel Age:- 29 years


    Registration No:- 456932 Date:- 4 /8/21
    L.M.P.:- 5/1/21 E.D.D:- 12/10/21
    Obstetrical Score: G1 P0 L0 A0
     MEDICAL HISTORY:
    Anaemia: Present Heart Disease:- Absent
    Pulmonary Disease:- No any Allergy:- No any
    Other:- No any *H/o: RTI/STI/HIV:- No
    any

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

     PERSONAL HISTORY:
    Diet: Vegetarian Addiction: No any
    Likes: Drawing Dislikes: No any
    Bowel: Irregular Bladder: Increased
    frequency of micturation
    Tetanus Immunization: Taken

     SOCIOECONOMIC BACKGROUND:
    Religion: Hindu Family Income:
    Education: Husband – B.Com Wife: 12th pass
    Occupation: Husband – Job Wife: House wife
     MENSTRUAL HISTORY:
    Menarchy: At 14 years Duration: 5 days
    Interval: 27 days Flow: Regular

     MARITAL HISTORY:
    Age of marriage: 25 year Years Married: 4
    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

    Nil

     GENERAL EXAMINATION:
    General Condition: Normal Temperature: 37.5 c
    Pulse: 82 bpm Respiration: 20/min
    Blood Pressure: 120/70 mmhg Other Features: No
    any
    Pallor: Present Oedema: Absent
    Icterus: Absent Lymphadenopathy: Absent
    Breasts: Right: Normal Left: Normal
    Nipples: Right: Everted Left: Everted
     SYSTEMIC EXAMINATION:
    1. Nervous System: Patient is conscious and no any symptoms related to
    nervous system
    2. Cardiovascular System: S1 & S2 heard with the blood pressure of
    120/70mmhg.
    3. Respiratory System: Patient has respiratory rate of 20/min with the
    normal lung sounds
    4. Gastrointestinal System: Patient has regular bowel movements and
    no any other complains related to GI system
    5. Reproductive System: Uterus is enlarged at size of 28cm and the
    abdominal girth is 66cm. The uterus is soft
    6. Musculo-skeletal System: The patient has complain of back pain and
    leg cramps
    7. Integumentary System: The presence of chloasma with 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)
    4/8/ 68kg 120/7 absent abse 28cm 66cm 28 Breech 120 RSA
    21 0mmh nt weeks bpm
    g

     INVESTIGATIONS:
    Blood group: A positive Rh: Positive
    Haemoglobin: 9.5 gm/dl VDRL:
    Negative
    HIV: Negative Others: No any

     TREATMENT GIVEN:
    Calcium 500mg 2BD
    Iron 40mg 2BD

     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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