Antenatal follow-up consult:
Subjective:
- Patient presents today for a routine antenatal follow-up at 28 weeks gestation. She reports feeling well, with no current complaints. She denies any vaginal bleeding, abdominal pain, or contractions. She reports good fetal movement.
- Past medical history is unremarkable. No previous surgeries.
- Medications: Prenatal vitamins, 600mg Calcium, 400mcg Folic Acid. No herbal supplements.
- Social history: Patient is a non-smoker and does not consume alcohol. She is employed and has a supportive partner.
- Allergies: NKDA.
Objective:
- Vital signs: BP 120/70 mmHg, HR 80 bpm, RR 16, Temp 37.0°C.
- Physical examination findings: Fundal height 28 cm. Fetal heart tones auscultated at 140 bpm. No edema noted.
- Fetal heart rate: 140 bpm.
- Fundal height: 28 cm.
- Ultrasound findings: Confirmed single viable intrauterine pregnancy. Appropriate fetal growth for gestational age. Placenta appears normal.
Assessment:
- Assessment of maternal health: Patient is doing well. No signs of pre-eclampsia or gestational diabetes.
- Assessment of fetal health: Fetal growth appropriate for gestational age. Fetal well-being appears normal.
- Any complications or concerns: None.
Plan:
- Plan for ongoing antenatal care: Continue routine antenatal care. Discussed importance of regular fetal movement monitoring.
- Medications or supplements prescribed: Continue current medications.
- Referrals to specialists or additional tests: None at this time.
- Patient education and counseling provided: Discussed signs and symptoms of preterm labor. Reviewed importance of healthy diet and exercise.
- Next follow-up appointment: Scheduled for 4 weeks on 29 November 2024.
Antenatal follow-up consult:
Subjective:
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe past medical history, previous surgeries] (only include describe past medical history, previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention medications and herbal supplements] (only include mention medications and herbal supplements if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention allergies] (only include mention allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Objective:
- [vital signs] (only include vital signs if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [physical examination findings] (only include physical examination findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [fetal heart rate] (only include fetal heart rate if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [fundal height] (only include fundal height if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [ultrasound findings] (only include ultrasound findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Assessment:
- [assessment of maternal health] (only include assessment of maternal health if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [assessment of fetal health] (only include assessment of fetal health if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [any complications or concerns] (only include any complications or concerns if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Plan:
- [plan for ongoing antenatal care] (only include plan for ongoing antenatal care if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [medications or supplements prescribed] (only include medications or supplements prescribed if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [referrals to specialists or additional tests] (only include referrals to specialists or additional tests if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [patient education and counseling provided] (only include patient education and counseling provided if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [next follow-up appointment] (only include next follow-up appointment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
