Give me proper history taking in antenatal case taking ANC visit in community medicine clinical posting 2nd year mbbs student
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I have all the content I need from your notes. Now let me give you a complete, properly formatted ANC history taking write-up based on your case (Dhanshri) and the standard format expected in community medicine clinical postings.
ANC Case History Taking - Community Medicine Clinical Posting
(2nd Year MBBS Standard Format)
ANC CASE - 1
SECTION 1: BIODATA / IDENTIFICATION DATA
| Parameter | Details |
|---|---|
| Name | Dhanshri |
| Age | 21 years |
| Education | B.A. English |
| Address | 11A Manreemagar, Chambakkam |
| Blood Group | O positive (O+) |
| Obstetric Formula (GPL) | G1 P0 L0 (Primigravida) (Note: your notes say G1P1L1 - correct to G1P0L0 if she hasn't delivered yet) |
| Diet | Mixed diet (non-vegetarian) |
| Religion | (to be filled) |
| Occupation | Homemaker / (to be filled) |
SECTION 2: FAMILY DETAILS
| Parameter | Details |
|---|---|
| Husband's Name | Pravin |
| Husband's Age | 29 years |
| Husband's Occupation | (to be filled) |
| Husband's Education | (to be filled) |
| Type of Family | Nuclear / Joint (to be filled) |
| Monthly Family Income | (to be filled) |
SECTION 3: SOCIOECONOMIC STATUS
- Ration Card: Not available
- BPL Card: (to be filled)
- Loan: None
- Health Insurance / Pradhan Mantri Suraksha Bima Yojana: Not enrolled
- Janani Suraksha Yojana (JSY): (to be filled - very important in community medicine)
- PMMVY (Pradhan Mantri Matru Vandana Yojana): (to be filled)
- Socioeconomic Class (Modified B.G. Prasad / Kuppuswamy Scale): (calculate using income + education + occupation)
SECTION 4: HEALTH CARE FACILITY UTILIZATION
- Nearest Health Facility: Urban Health & Wellness Centre (UHWC)
- Time taken to reach: 5-10 minutes
- Mode of transport: (to be filled)
- ANC Visit Facility: Urban Health & Wellness Centre
- Attending health worker: ASHA / ANM (to be noted)
SECTION 5: OBSTETRIC HISTORY
- LMP (Last Menstrual Period): 29th November 2025
- EDD (Expected Date of Delivery): 5th September 2026
- (Calculated by Naegele's Rule: LMP + 9 months + 7 days OR +280 days)
- Gestational Age at Present Visit: (calculate from LMP to date of visit)
- Obstetric Formula: G₁ P₀ L₀ - Primigravida
SECTION 6: CHIEF COMPLAINT
No chief complaints - Routine antenatal visit
(This is a routine ANC visit with no presenting symptoms. Always mention this clearly.)
SECTION 7: HISTORY OF PRESENT PREGNANCY (Trimester-Wise)
1st Trimester (0-13 weeks)
| Item | Status |
|---|---|
| Pregnancy confirmation | Home kit test (UPT positive) - spontaneous pregnancy |
| Registration of pregnancy | Done |
| USG - Dating scan | Done |
| Folic acid supplementation | Started (400 mcg/day) |
| Calcium tablet | Started |
| Weight at booking | 47 kg |
| Nausea/vomiting | (to be filled) |
| Fever/infections | None |
| Any bleeding (threatened abortion) | None |
| Complications | None |
2nd Trimester (14-28 weeks)
| Item | Status |
|---|---|
| Quickening felt | Yes - Present |
| Td2 vaccination | Taken |
| IFA (Iron-Folic Acid) tablet | Taken regularly (frequently noted) |
| Calcium tablet | Continued |
| Weight gain | 47 kg → 50 kg (3 kg gain - appropriate) |
| USG - Anomaly scan | Done |
| No. of ANC visits in this trimester | 6-7 times (total) |
| Complications | None |
3rd Trimester (29 weeks - delivery)
| Item | Status |
|---|---|
| Calcium tablet | Continuing |
| Fetal movements | Present (quickening noted) |
| Weight gain | Moderate - present but not excessive |
| Danger signs | None |
| Swelling of feet/face | (to be filled) |
| Headache / visual disturbances | (to be filled) |
| Reduced fetal movements | None reported |
| Birth preparedness / plan | (to be filled) |
SECTION 8: DANGER SIGNS (MUST ASK AND DOCUMENT)
These are the FLAGGED RED SIGNS that every ANC visit must screen for:
| Danger Sign | Present / Absent |
|---|---|
| Severe headache | Absent |
| Blurring of vision | Absent |
| Convulsions | Absent |
| Severe abdominal pain | Absent |
| High fever | Absent |
| Excessive vomiting | Absent |
| Severe pallor / breathlessness | Absent |
| Reduced / absent fetal movements | Absent |
| Bleeding per vaginum | Absent |
| Swelling of face, hands, feet | Absent |
Patient has NO danger signs - low-risk pregnancy
SECTION 9: PAST OBSTETRIC HISTORY
(For primigravida like Dhanshri - Not applicable. Write "Primigravida - No previous pregnancies")
| Previous Pregnancy | Mode of Delivery | Birth Weight | Complications | Outcome |
|---|---|---|---|---|
| - | - | - | - | Primigravida |
SECTION 10: PAST MEDICAL & SURGICAL HISTORY
- Hypertension: Not present
- Diabetes mellitus: Not present
- Tuberculosis: (to be filled)
- Thyroid disorders: (to be filled)
- Any surgery: (to be filled)
- Previous blood transfusions: (to be filled)
- Drug allergies: (to be filled)
SECTION 11: FAMILY HISTORY
- Hypertension in family: (to be filled)
- Diabetes in family: (to be filled)
- Twin pregnancies: (to be filled)
- Congenital anomalies: (to be filled)
SECTION 12: PERSONAL HISTORY
- Menstrual history: Regular cycles prior to pregnancy
- Dietary habits: Mixed diet (both veg + non-veg)
- Sleep: Adequate (to be verified)
- Bowel/bladder habits: Normal
- Addiction/substance use: Nil (tobacco, alcohol)
- Physical activity: (to be filled)
SECTION 13: IMMUNIZATION STATUS
| Vaccine | Status |
|---|---|
| Td1 (Tetanus-Diphtheria - 1st dose) | (to confirm - usually given at 1st ANC visit, ≥16 weeks) |
| Td2 (given 4 weeks after Td1) | Given |
| Td Booster (if received Td in last 3 years) | (as applicable) |
SECTION 14: INVESTIGATIONS
| Investigation | Result | Normal Range | Interpretation |
|---|---|---|---|
| Urine routine | Normal | - | No abnormality |
| Urine Albumin | Normal (Nil) | Nil | No proteinuria |
| Urine Sugar | Normal (Nil) | Nil | No glycosuria |
| Blood Group | O positive | - | No Rh incompatibility risk |
| Hb (Haemoglobin) | 11.5 g/dL | ≥11 g/dL in pregnancy | Mild anaemia / low-normal |
| VDRL (Syphilis) | Negative | Negative | Normal |
| HIV | Negative | Negative | Normal |
| HBsAg (Hepatitis B) | Negative | Negative | Normal |
| Blood Pressure | Normal | <140/90 mmHg | No hypertension |
| Blood Sugar (GDM screen) | (to be filled) | - | - |
| Weight | 50 kg (last recorded) | - | Adequate gain |
Note on Hb: 11.5 g/dL is borderline low in pregnancy (WHO cut-off for anaemia in pregnancy is <11 g/dL). She is just above the threshold but should continue IFA tablets and dietary iron counselling.
SECTION 15: COUNSELLING & SERVICES PROVIDED (For Your Record)
Under RMNCH+A Program / LaQshya / PM-SUMAN guidelines:
| Service | Given / Advised |
|---|---|
| IFA tablets (180 tablets total) | Yes - given regularly |
| Calcium tablets (360 tablets total) | Yes - given |
| Folic acid (1st trimester) | Yes - given |
| Dietary counselling | (to document) |
| Birth preparedness counselling | (to document) |
| Breastfeeding counselling | (to document) |
| JSSK benefits explained | (to document) |
| Emergency contact / referral | (to document) |
SECTION 16: ANC VISIT SCHEDULE (As Per GoI Guidelines - 4 Antenatal Visits)
| Visit | Timing | Done/Pending |
|---|---|---|
| 1st ANC | By 12 weeks (1st trimester) | Done |
| 2nd ANC | 14-26 weeks | Done |
| 3rd ANC | 28-34 weeks | Done |
| 4th ANC | 36 weeks onwards | (current / pending) |
Under PMSMA (Pradhan Mantri Suraksha Matritva Abhiyan), a special 9th-of-every-month ANC clinic is provided. Ask if the patient attended any PMSMA camp.
SUMMARY OF THE CASE
Dhanshri, 21-year-old primigravida (G1P0L0), with LMP 29th November 2025 and EDD 5th September 2026. She is at approximately 31-32 weeks of gestation (as of July 2026). She attends the Urban Health & Wellness Centre for ANC follow-up with no complaints. Pregnancy is spontaneous. She has been compliant with IFA, calcium, and folic acid supplementation. Td2 vaccination received. Dating scan and anomaly scan (USG) done. No danger signs present. All investigations within normal limits. Hb is 11.5 g/dL (borderline - adequate supplementation needed). Blood group O+, VDRL/HIV/HBsAg negative. Socioeconomic status: No ration card, no health insurance - needs to be enrolled in government maternal health schemes (JSY, PMMVY).
TIPS FOR YOUR COMMUNITY MEDICINE POSTING
- Always calculate gestational age from LMP at time of writing the case
- GPL formula - G = total pregnancies, P = deliveries ≥28 weeks, L = living children. For primigravida: G1P0L0
- Socioeconomic assessment using Modified B.G. Prasad scale is mandatory in community medicine
- Enumerate ALL 10 danger signs and clearly state which are absent
- Mention government schemes - JSY, PMMVY, JSSK, PMSMA in your case write-up
- IFA = 180 tablets, Calcium = 360 tablets (total expected in full pregnancy)
- VDRL, HIV, HBsAg - these are mandatory screening tests under NACP/RMNCH+A
- Write the ANC visit number at the time of your visit (this was the how-many-th visit)
Your notes are quite well done! The main things to add/complete are:
- Full socioeconomic classification (Kuppuswamy/BG Prasad scale)
- Government scheme enrollment status
- Current gestational age at time of visit
- Correcting GPL to G1P0L0 (since she hasn't delivered yet)
- Completing personal/family history sections
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