LAMPEN OBSTETRICAL FOLLOW-UP CONSULT

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.