2. • MY PATIENT MRS. SADHNA W/O MR.DEVI SINGH 23 YEARS OLD HINDU, RESIDENT
OF GAYATRI NAGAR, BHOPAL, HOMEMAKER,
• BELONGING TO LOWER MIDDLE SOCIOECONOMIC CLASS ACCORDING TO
MODIFIED KUPPUSWAMY SCALE.
• BOOKED AT ANGANWADI FOR 8.5 MONTHS AND IMMUNISED.
• PATIENT IS P2L2 POST EM LSCS DAY- 4 WITH PREVIOUS 1 LSCS WITH POLIOMYELITIS
• AT PRESENT NO COMPLAINTS
• NO C/O EXCESSIVE BLEEDING OR DISCHARGE.
• NO C/O CRACKING OF NIPPLES ,PAIN IN BREAST, BREAST ENGORGEMENT.
• NO C/O FEVER, ANY URINARY COMPLIANTS.
3. HISTORY OF PRESENTING ILLNESS
• PATIENT WAS APPARENTLY ALRIGHT 4 DAYS BACK THEN SHE REPORTED TO
LABOUR ROOM AT 12 PM WITH
• H/O AMENORRHEA SINCE 8.5 MONTHS
• C/O PAIN IN LOWER ABDOMEN WHICH WAS INSIDIOUS IN ONSET,NON
PROGRESSIVE IN NATURE,RADIATING TO LOWER LIMBS AND BACK WITH PAIN
AT PREVIOUS LSCS SCAR SITE.
• NO C/O BURNING MICTURITION, FREQUENCY OF MICTURITION AND DYSURIA.
• NO C/O BLEEDING PV OR LEAKING PV
• PATIENT WAS PERCEIVING FETAL MOVEMENT WELL
4. • PATIENT WAS EXAMINED AND WAS ADVISED ADMISSION.
• PATIENT WAS ADMITTED IN LABOUR ROOM AND WAS COUNSELLED AND
TAKEN FOR EMERGENCY LSCS IN VIEW OF PREVIOUS 1 LSCS WITH SCAR
TENDERNESS.
• A MALE BABY OF 2.585KG ON 14/7/2025 ALIVE AND HEALTHY WAS
DELIVERED AND CRIED IMMEDIATELY AND BABY WAS KEPT IN NICU FOR
OBSERVATION ON PAEDIATRICIAN ADVICE.
5. OBSTETRIC HISTORY
• 7 YEAR OF NON-CONSANGUINEOUS MARRIAGE.
• 1ST
: FULL TERM LSCS- MALE, 12:25 PM, 3.1 KG ALIVE AND HEALTHY ADMITTED
IN NICU
• CAUSE OF PREVIOUS LSCS: LIMB DEFORMITY (POLIO)
6. MENSTRUAL HISTORY
• SHE HAD REGULAR PAST MENSTRUAL CYCLE AT INTERVAL OF 28 DAYS LASTING
FOR 4-5 DAYS WITH NORMAL FLOW WITHOUT DYSMENNORHEA.
• LMP- 23/10/2024
• EDD- 30/7/2025
• POG- 37 WEEKS 5 DAYS
• 37 WEEKS 5 DAYS BY 22 WEEK SCAN
7. HISTORY OF PRESENT PREGNANCY
BOOKED PATIENT AT PEOPLES HOSPITAL,BHOPAL
IN FIRST TRIMESTER :
• PREGNANCY CONFIRMED AT HOME BY URINE PREGNANCY TEST AT 1 ½ MONTHS AMENORRHEA
• RECEIVED FOLIC ACID.
• NO C/O EXCESSIVE VOMITING
• NO C/O FEVER, CHILLS, RASHES.
• NT-NB SCAN DONE AT 12 WEEKS 4 DAYS
• NO H/O ANY RADIATION EXPOSURE,OTHER DRUG INTAKE ,TOBACCO CHEWING, SMOKING/
ALCOHOL INTAKE.
8. SECOND TRIMESTER :
• QUICKENING FELT AT AROUND 5 MONTHS
• HAD REGULAR INTAKE OF IRON AND CALCIUM
• IMMUNISED WITH 2 DOSES OF DT VACCINE
• TARGET SCAN DONE AT 19 WEEKS 5 DAYS
THIRD TRIMESTER:
• TOOK IRON AND CALCIUM
• PT HAD RECEIVED 2 DOSES OF BETNESOL INJECTION 36 WEEKS OF AMENORRHEA ON
28TH
AND 29TH
JUNE.
• PT WAS APPARENTLY ALRIGHT 4 DAY BACK AND WAS ADMITTED IN PEOPLES HOSPITAL
FOR PAIN IN ABDOMEN ON 14/7/2025
• HAD TOTAL WEIGHT GAIN OF …12 KG
9. PAST HISTORY
• H/O POLIOMYELITIS SINCE 6 YRS OF AGE
• NO H/O HTN
• DM
• TB
• ASTHMA
• THYROID DISORDERS
• BLOOD AND BLOOD PRODUCTS TRANSFUSIONS
• MINOR /MAJOR SURGERY OR ILLNESS
10. PERSONAL HISTORY
• PATIENT IS VEGETARIAN
• TOTAL CALORIE INTAKE:……2100…. KCAL
• EXPECTED CALORIE INTAKE:2500 KCAL, DEFICIT BY- 400 KCAL
• NORMAL SLEEP CYCLE
• NORMAL BLADDER/BOWEL HABITS
• NO ANY ADDICTIONS
12. FAMILY HISTORY
• NOT SIGNIFICANT
• NO H/O POLIOMYELITIS IN FAMILY
( NO H/O HTN, DM, THYROID DISORDER, TB, ASTHMA
TWINS AND ANY CONGENITAL MALFORMATION IN ANY FAMILY MEMBER)
13. GENERAL EXAMINATION
• GAIT: ANTALGIC/LIMPING GAIT+
• AVERAGE BUILT
• BMI- …25..KG/M2
• PT IS CONSCIOUS, ORIENTED TO TIME, PLACE AND PERSON.
• GC :FAIR
• TEMP: AFEBRILE
• PALLOR +
• NO EDEMA, ICTERUS, CYANOSIS
• NO CLUBBING
• NO ENLARGED THYROID GLAND
• NO ENGORGED NECK VEINS
• NO LYMPHADENOPATHY
Tongue: moist pink, no signs of dehydration
14. • PULSE – 80 BPM, REGULARLY REGULAR, NORMO-VOLUMIC
• BP :100/76MMHG MEASURED IN SITTING POSITION ON RIGHT UPPER ARM
• RESPIRATION RATE:16/MIN (THORACOABDOMINAL TYPE)
• B/L AIR ENTRY EQUAL
• S1S2HEARD,NO ADDED MURMUR
• BREAST EXAMINATION
B/L BREAST SYMMETRICAL , SOFT
NO ANY DILATED VESSELS
NIPPLES EVERTED ,SECONDARY AREOLA SEEN
MONTGOMERY TUBERCLES PRESENT
NO ANY TENDERNESS/ENGORGEMENT, MILK DISCHARGE +
15. • PER ABDOMEN
INSPECTION- ABDOMEN IS SCAPHOID, STRIAE GRAVIDARUM + LINEA NIGRA +,
UMBILICUS INVERTED NORMAL
DRESSING DRY IN PLACE
NO ANY DILATED VEINS, HERNIA
NO ANY DISTENSION
16. PALPATION -UTERUS PALPABLE PER ABDOMEN (AROUND 18 WEEKS) : 4CM BELOW UMBILICUS
WELL RETRACTED,NON TENDER
NO SPLENOMEGALY, NO HEPATOMEGALY, NO RENAL ANGLE TENDERNESS
AUSCULTATION- BOWEL SOUNDS PRESENT
• LOCAL EXAMINATION- LOCHIA SEROSA+
NO ANY FOUL SMELL
17. BABY DETAILS
• MALE
• TIME OF BIRTH: 3:15PM
• BIRTH WEIGHT: 2.5 KG
• APGAR AT 1 MIN 7/5 MIN 8
• SHIFTED TO NICU AFTER BIRTH FOR OBSERVATION LATER SHIFTED MOTHERS SIDE
AFTER2 HOURS OF BIRTH.
• BREASTFEEDING: WELL ESTABLISHED(EVERY 2-2.5 HRLY)
• SUCKING REFLEX : PRESENT
• VITALS: STABLE; MOTHER’S SIDE
• PASSED URINE/STOOL : WITHIN 24HRS OF BIRTH
• VACCINATION DONE ON DAY 1 OF BIRTH(BCG/ OPV-0/HEPATITIS B-0)
18. DIAGNOSIS
• P2L2 POST EM LSCS DAY 4 WITH POLIOMYELITIS
• INDICATION: PREVIOUS 1 LSCS WITH SCAR TENDERNESS WITH POLIOMYELITIS
