ANTENATAL

CASE STUDY
FORMAT
 SUB- OBSTETRICS AND GYNECOLOGY

SUBJECT :

TOPIC :

SUBMITTED TO :

SUBMITTED BY :

YEAR & COURSE OF STUDY :

COLLEGE NAME :

SIGNATURE OF THE STUDENT :

SIGNATURE OF SUPERVISOR :

DATE :
SELF INTRODUCTION:-

PATIENT INTRODUCTION:-

IDENTIFICATION DATA:-

Name: :
Age :
Sex :
I.P No :
Ward :
Hospital :
Address :
Marital status :
Educational status :
Occupational status :
Husband name :
Nationality :
Religion :
Date of admission :
Diagnosis :
Obstetrical score :

HISTORY OF PRESENT ILLNESS:-

Chief Complaints:-
Present history of illness:-
Final Diagnosis:-

PAST MEDICAL HISTORY AND SURGICAL HISTORY:-

Past Medical History:-
History of Hospitalization:-
Past Surgical History:-

OBSTETRICAL HISTORY:-

OBSTETRIC SCORE :
LMP :
EDD :
POG :

PRESENT OBSTETRIC HISTORY:-

PAST OBSTETRIC HISTORY:-

Patient had a significant past obstetric history, patient had one female child with normal
delivery.

S. Date Wt. Term/ Abortion Type of Se Live/ Immunizati Remark

No of of preterm Delivery x stillbirth on
. birth baby
-

ANTENATAL CARE:-

MENSTRUAL HISTORY:-

FAMILY HISTORY:-

FAMILY COMPOSITION:-

S. Name of the Relationshi Age Se Educatio Occupation Marital Health

no in x status
family p n status status
years
Member to mother Status

FAMILY TREE:-
SOCIO ECONOMIC DATA:-

PERSONAL HISTORY:-

Immunization :-

Smoking :-

Alcoholism :-

Use of drugs :-

Hobbies :-

NUTRITIONAL PATTERN:-

ELIMINATION PATTERN:-

PERSONAL HYGIENE:-

INVESTIGATION CHART:
Following investigations were done for the patient:

SNO. INVESTIGATION PATIENT NORMAL REMARK

DONE VALUE VALUE
1. Hemoglobin
2. TLC
3. RBC
4. Platelet
5. Blood Group and Rh
6. HVB
7. HIV
8. VDRL

TREATMENT CHART:

SNO. DRUG NAME ROUTE/ ACTION SIDE EFFECTS

FREQUENCY
PHYSICAL ASSESSMENT:- (CARDINAL SIGNS)

S No. Vital Signs Patient’s Normal Value Remarks

Value
1. Blood Pressure

2. Temperature

3. Pulse

4. Respiration

PHYSICAL EXAMINATION (HEAD TO FOOT ASSESSMENT):-

 General assessment:
Appearance :
Body built :
Sensorium :
Emotional state :
Posture :
Body odor :
Breath :
Weight :
Height :

 SKIN CONDITION:
Skin color :
Skin lesions :
Temperature :
Texture :
Turgor & elasticity :
Edema/ puffiness :
Hyperpigmentation of : areola nevi
Linea nigra
Chloasma

 Hair:
Color :
Distribution :

 Nails:
Hygiene :
Condition :
Angle of nail beds :
Nail bed color :
 Head & face
Shape :
Facial appearance :
Cyanosis :
Tenderness :

 Eyes:
Eye brows :
Eye lashes :
Eye lids :
Eye Shape, appearance :
Sclera :
Cornea :
Pupils :
Vision :

 Ears:
Position :
Shape & size :
Tympanic membrane :
Hearing :
Discharge :

 Nose:
External nose
Size :
Shape :
Internal nasal mucosa :

 Mouth:
Lips
Color :
Shape :
Condition :
Teeth :
Gums :
Tongue :
Oropharynx :
Tonsils :
Uvula :
Palate :

 Neck
Range of motion :
Thyroid :
Lymph node :

 Thorax & lungs:

 Respiratory rate :
Rhythm :
Shape :
Chest wall movement :
Lung auscultation : Vesicular sounds
: Wheezing / Rhonchi
: Crepitations

 Chest & axilla

Lymph node :

 Heart :
:
Breast
Shape :
Lump :
nipple :

 Abdomen:
(i) Inspection:

Skin changes :
Lesions :
Size :
Umbilicus :

(ii) Palpation:
Fundal
Fundal height :
Abdominal girth :

Lateral
Fetal lie :
Pelvic
Presentation :
Presenting part :

(iii) Auscultation:
 Perineum : os -
cx-
membrane-
pelvis-
station-

 Genitalia:
 Rectum :
Female genitalia :

 Back:
Vertebral column :
Joints :

 Extremities:
(i) Upper extremities :
Range of motion :
Syndactyl :
Polydactyl :
Oedema :

(ii) Lower extremities :

Range of motion :
Varicose vein :
Homans sign :

ANATOMY AND PHYSIOLOGY RELATED TO DISEASE CONDITION

DISEASE CONDITION:

TYPES :-

CAUSES:-

CLINICAL MANIFESTATION

DIAGNOSTIC EVALUATION

COMPLICATION compare patient picture with book picture

MEDICAL MANAGEMENT

SURGICAL MANAGEMNT

DIETARY MANAGEMNT

NURSING MANAGEMENT

NUSRING DIAGNOSIS

NURSING CARE PLAN

HEALTH EDUCATION

RESEARCH IMPLEMENTATION

SUMMARY
CONCLUSION

REFERENCES