2. Patient’s Particulars
• Name: Mrs. SWARNA,w/o Mr. vijay
• Age: 22 yrs
• Address: Srinivaspura, Kolar .
• Occupation: Daily wage labourer
• Education: Unschooled
• Husband’s occupation: Daily wage labourer
• Husband’s education: Unschooled
• Socio-economic status: Lower SE status
• Date of examination: 28/04/23
3. Primigravida with 8 months of amenorrhea
Chief complaint
• C/o easy fatiguability for past 2 months
• C/o generalized weakness for past 2 months
4. History of Presenting Illness
• C/o easy fatigability and generalized weakness since 2 months
• Patient was apparently normal 2 months back then gradually
devoloped easy fatiguability and generalized weakness
• Previously, the patient was able to manage work and household
works but since past 2 months gets tired on minimal work, that is
relieved on rest.
5. • No h/o palpitations/ chest pain
• No h/o bleeding per vagina/ bleeding per rectum/ hematemesis/
malaena/ easy bruisability
• No h/o passage of worms in stools
• No h/o reduced appetite/ constipation
• No h/o burning micturition/ increased frequency of micturition
• No h/o fever/ chronic cough
• No h/o numbness/ tingling sensation
History of Presenting Illness (contd)
6. Obstetric History
• Married life: 1 year
• Non consanguineous marriage
• LMP: 28.8.2022
• EDD: 4.6.2023
• Gestational age: 34 weeks 5 days
7. History of Present Pregnancy
1st Trimester
• Conceived spontaneously
• Confirmed pregnancy by UPT after 1 ½ months of amenorrhea
• Dating scan was done at 2 months and was told to be normal
• Folic acid tablets taken regularly
• Booking investigations were done
• No h/o excessive vomiting
• No h/o bleeding per vagina/ pain abdomen
• No h/o fever/ burning micturition
• No h/o teratogenic drug intake/ radiation exposure
• No h/o pica (craving for abnormal food).
8. History of Present Pregnancy (contd)
2nd Trimester:
• Quickening felt at 5th month of pregnancy
• H/o swelling of both lower limbs from 5th month
• Anomaly scan done at 5th month and was told to be normal
• Iron and calcium supplementation was taken irregularly
• 2 doses of Inj. Td taken
• No h/o pain abdomen/ bleeding per vagina
• No h/o high BP readings/ headache/blurring of vision/ epigastric pain
9. 3rd Trimester:
• Patient continued to perceive fetal movements well
• H/o irregular antenatal checkups
• Growth scan was done- normal
• Blood investigations were done- Hemoglobin low(7.8g%) and was
adviced to take oral iron supplements twice daily
• Iron and calcium supplements was taken irregularly
• No h/o burning micturition/ increased frequency of micturition
• No h/o fever
History of Present Pregnancy (contd)
10. Menstrual History
• Regular menstrual cycles
• Duration of menstruation: 4-5days/ 28 days
• Amount of bleeding: Moderate flow
• Not associated with dysmenorrhoea/ passage of clots.
CONTRACEPTIVE HISTORY
• No h/o contraceptive use
11. Past History
• Not a known case of Hypertension/ Diabetes/ Tuberculosis/
Asthma/Epilepsy
• Not a known case of thyroid disorders/ cardiac diseases
• No h/o of any hospital admission/blood transfusion/surgery in the
past
• No h/o chronic drug intake.
12. Family History
• No h/o chronic diseases in the family
• No h/o genetic disorders/ blood dyscrasia in the family
• No h/o multiple gestations/ congenital anomalies
13. Personal History
• Diet: mixed (predominantly vegetarian)
• Apetite: Good
• Sleep: Adequate
• Bowel and bladder habits: Regular and normal
• Addiction: None
14. General Physical Examination
• Patient examined in sitting position
• Patient is comfortable during examination
• Patient is conscious, coherent and cooperative
• Pt is moderately built and poorly nourished
• Height: 155 cms, Weight: 44 kgs, BMI: 18.33 kg/m2
• Severe pallor present
• Grade 2 pedal edema upto ankles present in both lower limbs
• No icterus/ clubbing/ cyanosis/generalized lymphadenopathy
15. Head to Toe Examination
• Hair: Normal
• Eyes: Pallor present in the lower palpebral conjunctiva
• Oral mucosa: pallor present
• No cheilosis/ glossitis/ angular stomatitis present
• Nails: Pale, thin, brittle, flat. No koilonychia present
• Palms and soles: Pallor present
16. Systemic Examination
Vitals:
• Temperature: 97.5°F
• Pulse rate: 102 beats per minute, regular in rhythm
• BP: 110/70 mmHg, measured in the right arm, in sitting position
• RR: 24 cycles per minute
• JVP :normal
• Breast, thyroid and spine normal.
17. • CVS: S1 S2 heard, no murmurs heard
• RS: Normal vesicular breath sounds heard, no added sounds
• CNS: Normal, No neurological deficit.
• GI system: No organomegaly
Systemic Examination
18. Per Abdomen Examination
On Inspection:
• Size: Abdomen uniformly distended
• Shape: Longitudinal ovoid
• Suprapubic region: convex
• Umbilicus: central and everted
• Linea nigra and stria gravidarum present
• No scars/ sinuses/ dilated veins noted
• Fetal movements visible.
19. On Palpation:
• Fundal height corresponds to 32-34 wks
• Symphysio-fundal ht- 32 cms
• Uterus: relaxed
• Liquor: Scanty
Per Abdomen Examination (contd)
20. Obstetric grips:
• Fundal grip: soft, broad, non-ballotable fetal part felt s/o breech
• Lateral grip:
Right- Smooth, curved fetal part, with uniform resistance s/o
spine/ back.
Left- Irregular, knob-like structures s/o fetal limbs
• 1st pelvic grip: Hard, globular, ballotable part s/o head, not engaged
• 2nd pelvic grip: Head is not engaged
Per Abdomen Examination (contd)
21. On Auscultation:
• Fetal heart sound: present
• Site: situated at right spino-umbilical line
• FHR: 150 bpm
• Rhythm- regular.
Per Abdomen Examination (contd)
22. Summary
• A 22 years old, primigravida at 34weeks + 5 days of gestational age an
unbooked case, belonging to low SE status, presented with c/o easy
fatigability and generalized weakness.
• Irregular ante-natal checkups, Non compliance to oral iron
supplements.
• O/E, poorly nourished with severe pallor, G2 pedal edema,
tachycardia.
23. Diagnosis
A 22 year old primigravida with 34 weeks 5 days of gestation
with single live intrauterine fetus in longitudinal lie and cephalic
presentation with severe anemia not in failure for further
management.
25. On peripheral smear:
• Microcytic hypochromic RBCs
• WBCs: normal total count with normal cell distribution
• Platelets: Adequate
• No hemoparasites seen.
Investigations (contd)
