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Give one example
Reading File
The image shows a gynaecological and obstetric case history proforma from a nursing/midwifery practical record book (page 49). You asked for "one example" - I'll fill in a complete example case based on the form's fields.
Example: Filled Obstetric History Form
Menstrual History
- Age of Menarche: 13 years
- Cycle: Regular | Interval: 28-30 days
- Amount of bleeding: Moderate
- Associated Problems: Nil
- Treatment taken: No
Marital History
- Marital Status: Married
- Age at Marriage: 22 years
- Years of Marital Life: 3 years (stays with husband)
- Consanguineous Marriage: No
- Use of Contraceptive: No
- Any Treatment for Infertility: No
Obstetric History (Past)
- No. of Living Children: 1 (1 Girl, 0 Boys)
- Abortions: Nil (Spontaneous: Nil, MTP: Nil)
- Age of First Child: 1 year
- Any congenital abnormality in children: Nil
History of Previous Pregnancy (Table Row Example)
| S.No | Date/Month/Year | Pregnancy Events | Labour Events | Mode of Delivery | Nature of Puerperium | Baby Details |
|---|---|---|---|---|---|---|
| 1 | Jan 2023 | Term (40 wks), No complications | Spontaneous, Normal duration | Normal vaginal delivery (N/D) | Uneventful recovery | Female, 2.9 kg, Immunized, Healthy |
Present Obstetric History
- General Health during Present Pregnancy: Good
- Complaints during Pregnancy: Mild nausea in 1st trimester
- Morning Sickness: Yes (resolved by 14 weeks)
- Minor Ailments: Constipation (managed with diet)
- Date of First Visit / ANC Registration: 8 weeks gestation
- Gestational Age at First Visit: 8 weeks
- Immunization (T/T): Yes - 1st dose at 16 weeks, 2nd dose at 20 weeks
- Calcium, Iron & Folic Acid supplements: Yes - Tab. IFA 1 OD, Tab. Calcium 500 mg BD
- Other Medications: None
This is a standard antenatal case history format used in BSc Nursing / GNM clinical postings to document a pregnant woman's complete obstetric background, which helps assess risk factors and plan appropriate care.
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Give continue history
analyse_media
Here is the complete continued history for Case No. 7 - Sunita Devi, combining both pages:
ANTENATAL ASSESSMENT — CASE NO. 7
IDENTIFICATION PROFILE
| Field | Details |
|---|---|
| Name | Sunita Devi |
| W/o | Rama Krishna |
| Age | 26 years |
| Religion | Hindu |
| IP/OPD Reg. No | JP/2026/042 |
| Hospital | K H Patil Hospital |
| Date of Admission | 08/07/2026 |
| Address | Ambhabhavani Temple, Belageri, Gadag |
OBSTETRICAL SCORE
| G2 | P1 | L1 | A0 |
|---|---|---|---|
| LMP: 20/10/2025 | EDD: 27/07/2026 | Gestational Period: 37 weeks | Married: 4 years |
SOCIO-ECONOMIC HISTORY
- Education: Wife - PUC | Husband - PUC
- Occupation: Wife - Homemaker | Husband - Farmer
- Family Income: Rs. 18,000/- per month
- Type of House: Pucca | Ventilation: Adequate
- Sanitation Facilities: Clean
FAMILY HISTORY
- Type of Family: Nuclear
- No. of Family Members: 4 (Adults: 3, Children: 1)
- Hereditary Diseases: Mother had HTN in pregnancy (significant - patient at risk for gestational hypertension/preeclampsia)
- History of Twins: None
- Any other Significant History: None
PERSONAL HISTORY
- Sleep: Disturbed
- Appetite: Decreased
- Allergy: Nil
- Habits/Addiction: Nil / No
- Bladder & Bowel Habits: Normal (No constipation/incontinence)
- Diet: Vegetarian | 3 meals/day
- Significant diet habits in pregnancy: No
PAST MEDICAL & SURGICAL HISTORY
| Previous Medical Illness | None |
| Childhood illness (Hepatitis/TB/Diabetes) | None |
| Thyroid / Asthma / Epilepsy | None |
| Long-term drugs / Blood transfusion | None |
| Any other significant illness | None |
| Previous Surgery (Abdominal/Pelvic/Orthopedic) | None |
MENSTRUAL HISTORY (from page 49)
- Age of Menarche: 14 years
- Cycle: Regular | Interval: 26-30 days
- Amount of Bleeding: Moderate
- Associated Problems: Nil | Treatment: None
MARITAL HISTORY (from page 49)
- Marital Status: Married | Age at Marriage: 22 years
- Consanguineous Marriage: No
- Use of Contraceptive: No
- Treatment for Infertility: No
NURSING NOTES / RISK FLAG
Important: Family history of maternal HTN in pregnancy places Sunita at elevated risk for gestational hypertension or preeclampsia. BP monitoring, urine protein checks, and fetal growth assessment are essential at every ANC visit given she is now at 37 weeks gestation.
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