Following is the case presentation on Antenatal Care Case Presentation

1. MEDICO-SOCIAL CASE
PRESENTATION
ANTI NATAL CARE
Presented By : Dr. Kunal Modak
Guided By: Dr. Abhay Mudey
13/10/2015 1

2. General information
• Name : Payal Sachin Srivastav
• Age : 23
• Sex : Female
• Religion : Hindu
• Cast: OBC
• Address : w/o. Manoj Shrivastav, Ward No-06,
Near Jain Mandir, Nachangaon, Maharashtra .
• Occupation : Homemaker
• Ward : Lower Gynaec Ward ( no. 11 )
• Bed No: 08
13/10/2015 2

3. Continued….
• Date of Admission : 25.02.2016
• Date of Examination: 01.03.2016
• Total Monthly income of the family:
10,000/Month
• Total number of Family members: 5
• Per capita /month : Rs. 10,000/5= 2000/Month
• Socio economic status : Class II ( Modified B.G
Prasad classification)
13/10/2015 3

4. Chief Complaints
• Came for routine examination she diagnosed
for decreased fluid.
• H/O Amenorrhea since 9 months
13/10/2015 4

5. History of Present illness
• Patient was apparently normal, but when she
came for routine USG examination, she was
diagnosed with reduced liquor amni.
• For which she was admitted in our hospital on
25th Feb. 2016.
• No H/O vomiting
• No H/O Backache
• No H/O headache
13/10/2015 5

6. H/O Present Pregnancy
• ANC Registration- Registered at Anganwadi at
5th week , after confirmation of pregnancy by
Urine Pregnancy Kit at home.
• No. of ANC visits- she had 5 antenatal visits
till now 2 at Anganwadi and 3 at AVBRH.
• Investigations- Routine Blood and Urine
Investigations were done in 1st trimester. 3
times USG done till now at AVBRH.
13/10/2015 6

7. Continued….
• Non Consanguineous marriage
• Active Marital Life- 6 years
• H/O contraceptive used. (Condom)
• Gravidity/ parity- G2P2L1A0.
• LMP : 07/09/15
• EDD : 11/03/2016 (Negele’s formula)
• Tetanus Toxoid Immunization- 4th & 5th month
at the local PHC.
13/10/2015 7

8. Continued….
• No h/o Trauma
• No h/o bleeding P/V
• No h/o leaking P/V
• No h/o Decreased fetal movements
13/10/2015 8

9. Trimester History
• 1st Trimester-
• In 5th week, after missing her menses she used
Prega-sure urine pregnancy test (UTP) Kit. Got
positive result. Later she visited PHC. & got it
confirmed.
• C/O increased frequency of maturation.
• No C/O nausea, vomiting or vertigo.
• Routine blood & urine tests were done & were
found in normal range.
13/10/2015 9

10. Continued….
2nd Trimester-
• She was prescribed Iron, folic acid and calcium, but
had non compliance.
• Experienced quickening at 16th week.
• There after she could appreciate foetal
movements regularly.
3rd Trimester-
• USG done at 7th month : pregnancy was uneventful.
• At 9th month Usg was done as routine check up &
was diagnosed with decreased liquor ammount.13/10/2015 10

11. Menstrual history
• Menarche at 14 years of age.
• 5/30 days regular cycle.
• Not associated with dysmenorrhoea.
• No H/O passage of clots.
13/10/2015 11

12. Marital History
• Married before : 6 years
• Non Consanguineous marriage
• Conceived Soon after 3 months of marriage
with the 1st child.
• No H/O contraceptives were used before 1st
child.
13/10/2015 12

13. Obstetrics History
• 1st Male Child alive & healthy, 5 year old.
• Antenatal period was uneventful.
• Got T. T immunization once.
• Institutional delivery at AVBRH.
• H/O episiotomy.
• No H/O blood transfusion
• Baby cried immediately after birth & fed after
½ hour.
13/10/2015 13

14. Continued….
• No pr- lacteal feeds were given.
• Breast fed exclusively for 6 months.
• Continued Breast feeding for 1 year & 2 months.
• No H/O IUCD insertion.
• Was advised to use barrier methods.
• Periods established after 1 year & 5 months of
pregnancy.
• No post partum complications.
• Child is fully immunized to the age.13/10/2015 14

15. Past History
• No history of any chronic illness like
diabetes / hypertension/Asthma
• No history of T.B., STD ,RTI.
• No history of hospitalization, blood
transfusion etc.
• No H/O any surgical intervention
13/10/2015 15

16. Family Histroy
• Family consist of 5 members, joint type
family.
• Head of family: Manoj Shrivastava (Father in
law)
• Age: 52 years
• Education: 5th standerd.
• Occupation : Farmer
13/10/2015 16

17. Continued….
• No significant family history.
• No history of any chronic illness
Name Relation Age(Years) Education Occupation
Payal
Shrivastav
Self 23 10th Class Housewife
Sachin
Shrivastav
Husband 28 10th Class Farmer
Roshan
Shrivastav
Son 05 Balwadi Student
Manoj
Shrivastav
Father in Law 52 5th Class Farmer
Saraswati
Shrivastav
Mother in Law 49 Illiterate Housewife
13/10/2015 17

18. Continued….
Name Relation Age(Years) Education Occupation
Payal
Shrivastav
Self 23 10th Class Housewife
Sachin
Shrivastav
Husband 28 10th Class Farmer
Roshan
Shrivastav
Son 05 Balwadi Student
Manoj
Shrivastav
Father in Law 52 5th Class Farmer
Saraswati
Shrivastav
Mother in Law 49 Illiterate Housewife
13/10/2015 18

19. Dietary History
Calories (kcal) Proteins (gm)
Early morning- 1 cup tea (140ml) 62 1
2 toast(medium thick) 2 x 50 6x1.5
Breakfast- 1 cup milk (100 ml) 118 4
1 serving poha (95gm) 275 5.2
Lunch- 5 roti (30gm each) 5 x 90 5x 2.4
1 katori sabji (150ml) 150 1.7
1/2 katori dal (75 ml) 75 3.1
Evening- 1 cup tea (140ml) 62 1
2 breads (medium thick) 2 x 50 2x1.5
Dinner- 2 roti (30gm each) 4 x 90 4x2.4
1/2 katori dal(75ml) 75 3.1
Late night- 1 cup milk(100ml) 118 4
------------------ ---------
1945 6.7
13/10/2015 19

20. Continued….
• Energy requirement of sedentary female in
antenatal period is-
1900 + 350 =2250 kcal
• Energy deficit is 305 kcal.
• Protein requirement of this female is
48+23=71 gm
• Protein deficit is 14.3 gm
• Food fads- not present
13/10/2015 20

21. Personal History
• Mixed diet.
• Bladder & bowel habits normal & regular.
• No H/O exposure to STD’s
• No H/O drug allergy.
13/10/2015 21

22. Environmental History
• Stays in Pakka house with cemented floor .
• Single living room of 12x 15 square feet size
with a varanda of 12x5 square feet size used
as kitchen.
• Rooms has 2 window, 2 doors.
• Separate bathroom outside house.
• No separate laterine.
• No separate kitchen.
• LPG cooking.13/10/2015 22

23. Continued….
• Water supply from near by well.
• Storage of water in earthen pot covered with
lid.
• Drinking water from municipal tap inside the
house.
• No boiling of water for drinking purposes
• Sullage Disposal in open drain.
• Waste disposal at distance place.
13/10/2015 23

24. Treatment History
• Inj. Dexamethasone 2ml IM BD
• Tab. Multivitamin BD
• Tab. Folic Acid OD
• Tab. Iron OD
13/10/2015 24

25. General Examination
• Patient is conscious, co-operative & well
oriented to time place & person.
• Height: 146 cm
• Weight: 53 kgs
• Build: Moderate
• Nourishment: moderately nourished.
• Pallor: Present
• Clubbing:Abscent
• Icterus: Abscent13/10/2015 25

26. Continued….
• Icterus: abscent
• Pedal oedema : abscent
• Lymphadenopathy: Abscent
• Breast: Normal
• Spine: Normal
• Vital Signs:-
• B.P : 128/86 mmHg R.R : 20/min
• P.R : 86/min
• Temperature: Afebrile13/10/2015 26

27. Systemic Examinations
Abdominal Examination:
Inspection:
• Abdomen Distended
• Umbilicus Stretched & centrally placed
• Linea Nigra Present
• Striae gravidarum Present
• No Scar marks seen.
13/10/2015 27

28. Continued….
• Palpation-
• Fundal grip-Below sternum, irregular parts
palpable.
• Rt/Lt lateral grips- back and fetal parts palpable
• Podalic grip- head floating.
Fetal movements felt.
• Auscultation-
• Normal bowel sounds heard.
• FHS present.(140/min) Heard13/10/2015 28

29. • Foetal hart sounds heasrd at Rt. Lower
quadrant as 140 beats per mins.
Per vaginal Examination
• No discharge
• OS Closed. (as Per Records)
13/10/2015 29

30. Respiratory System:
Normal Breath Sounds heard all over the lung field.
Cardiovascular System
S1 S2 Heard
No murmurs heard
Central Nervous System
No focal or neurological Deficit
13/10/2015 30

31. Continued….
Breast Examination
• No tenderness
• Breasts are not engorged.
• No distended veins visible.
• Areola- pigmented
• Nipples- enlarged, erectile and pigmented
• Secretions- absent
• No inverted or cracked nipples.
13/10/2015 31

32. Summary
• Payal Sachin Shrivastav, 23 year old female,
living in pukka house at Surgaon educated
upto 10th std, complaints presently of
reduced liquor amni with obstratic score of
G2P2L1A0.
13/10/2015 32

33. Provisional Diagnosis
• 23 year old Payal Sachin Shrivastav is a 38
weeks gravid multipara with G2P1L1A0
presenting with IUGR.
13/10/2015 33

34. Proposed Management
Investigations
• Hb
• TLC/DLC
• Urine examination
• USG
13/10/2015 34

35. Proposed management for
Pregnant Women
• Motivation for institutional delivery.
• Health education to mother-to-be about diet
and
her health.
• Dietary counselling, advise for frequent and
nutritious diet.
• Menu planning.
13/10/2015 35

36. Continued….
• Contraceptive counselling is must - Counsel
about permanent methods of contraception.
• After assessment of blood hemoglobin,
parental (ferric forms) should be advised.
13/10/2015 36

37. 13/10/2015 37