Antenatal Consultation Note

Date: 1 November 2024 Patient Name: Sarah Jenkins SUBJECTIVE Ms. Sarah Jenkins, a G2P1 at 28 weeks and 4 days gestation, presents for a routine antenatal consultation. She expresses general well-being but reports occasional mild lower back ache. - Gestation: 28 weeks 4 days - Expected Date of Delivery (EDD): 25 January 2025, calculated from last menstrual period (LMP). - Presenting Complaint: Occasional mild lower back ache, otherwise no new concerns. - Obstetric History: G2P1 (1 live birth, 1 miscarriage at 8 weeks). Previous pregnancy was uncomplicated, resulting in a healthy term delivery via spontaneous vaginal delivery in 2022. - Gynaecological History: Regular menstrual cycles (28-day cycle), no history of abnormal smears. Used combined oral contraceptive pill prior to current pregnancy. No history of gynaecological infections or conditions. - Past Medical History: No significant past medical history. No chronic conditions. - Past Surgical History: Appendectomy in 2010. - Medications: Prenatal vitamins daily, Folic Acid 400mcg daily. - Allergies: Penicillin (rash). - Family History: Maternal grandmother had gestational diabetes. No history of pre-eclampsia or other significant genetic conditions. - Social History: Married, works as a primary school teacher. Non-smoker, rarely consumes alcohol (ceased entirely during pregnancy). No illicit substance use. OBJECTIVE - Weight at start of pregnancy: 65 kg - Current weight: 78 kg - Abdominal Examination: Fundal height measures 29 cm, consistent with gestational age. Fetal heart sounds heard at 140 bpm, regular. Fetus in longitudinal lie, cephalic presentation. No uterine tenderness. Minimal oedema noted in ankles bilaterally. - Blood pressure 120/78 mmHg, pulse 72 bpm, respiratory rate 16 breaths/min. Urine dipstick negative for protein and glucose. ULTRASOUND Recent ultrasound scan at 28 weeks showed appropriate fetal biometry for gestational age. Estimated fetal weight 1200g. Amniotic fluid volume within normal limits (AFI 14 cm). Placenta anterior, not previa. No structural abnormalities noted. ASSESSMENT 1. Uncomplicated singleton pregnancy at 28 weeks 4 days gestation. 2. Mild lower back ache, likely musculoskeletal due to pregnancy-related changes. 3. Adequate fetal growth and well-being confirmed by ultrasound. PLAN 1. Continue antenatal care as per local guidelines. - Advise on back care: gentle stretching, heat packs, maintaining good posture. - Recommend a maternity support belt for back discomfort if conservative measures are insufficient. 2. Routine blood tests to be booked for 30 weeks (Full Blood Count, Glucose Tolerance Test). 3. Discuss birth plan considerations at next visit. 4. Follow-up appointment scheduled in 4 weeks.