Obstetric Consultation Note
Plan
Discussed management plan including continuation of current medications and diet recommendations. Follow-up appointment scheduled for 1 December 2024. Referral to dietician for gestational diabetes management.
Age 32 Weight 75 kg Height 165 cm
Current Pregnancy
Gestation 28 weeks and 3 days Earliest scan 12 January 2024, showing a singleton pregnancy with estimated due date of 19 July 2024.
1st AN blds
Blood Group: A+, Rhesus: Positive, HIV: Negative, Syphilis: Negative, Hepatitis B: Negative, Rubella Immunity: Positive, Full Blood Count: Normal, RPR/VDRL: Negative, Glucose testing: Elevated, consistent with gestational diabetes.
Complications to date
Gestational diabetes diagnosed at 26 weeks. Occasional mild abdominal pain reported, resolved spontaneously. No vaginal bleeding.
Investigations
First trimester screening (private sector) - low risk for aneuploidy. Glucose tolerance test (public sector) - confirmed gestational diabetes. Anatomy scan at 20 weeks (private sector) - normal fetal anatomy. Urine analysis - no proteinuria.
Obstetric history
G2P1. One live birth (vaginal delivery at term, no complications). One miscarriage at 8 weeks (spontaneous, no surgical intervention).
Gynaecology history
Menarche at 13 years, regular 28-day cycles. No history of fibroids or PCOS. No prior hormonal therapy. No prior gynaecological surgical procedures.
Cycle prior to pregnancy Regular 28-day cycles, moderate flow. Smear 15 March 2023, normal, no HPV detected.
Gynaecology issues
No ongoing or past gynaecological conditions.
Abdo infxn/surgeries
Appendectomy at age 16. No history of abdominal infections.
Medications
Folic acid 400mcg daily (since pre-conception), Iron supplement 60mg daily, Prenatal multivitamin daily. Metformin 500mg twice daily (started after gestational diabetes diagnosis).
Allergies
Penicillin (rash). No known food or other allergies.
Obstetric Consultation Note
Plan
[Document management plan including recommendations, follow-up appointments, and any interventions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Age [Document patient's age] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Weight [Document patient's current weight in kilograms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Height [Document patient's height in centimetres] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Current Pregnancy
Gestation [Document current gestational age in weeks and days] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Earliest scan [Document date and findings of earliest ultrasound scan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
1st AN blds
[Document first antenatal blood test results including blood group, rhesus status, HIV, syphilis, hepatitis B, rubella immunity, full blood count, RPR/VDRL, and glucose testing if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Complications to date
[Document any complications experienced during the current pregnancy such as vaginal bleeding, abdominal pain, gestational hypertension, proteinuria, gestational diabetes, anaemia, or other antenatal concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Investigations
[Document all antenatal investigations including sonar scans, blood tests, urine analysis, genetic testing or procedures such as amniocentesis, and note whether performed in the public or private sector] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Obstetric history
[Document prior pregnancies with gravidity and parity (e.g. G3P2), include number of live births, miscarriages, stillbirths, ectopic pregnancies; note mode of delivery, complications such as pre-eclampsia, PPH, birth trauma or C-section indications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Gynaecology history
[Document menstrual history (age at menarche, cycle regularity), past diagnoses (e.g. fibroids, PCOS), previous treatments including hormonal therapy, and prior surgical procedures like LLETZ or hysteroscopy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Cycle prior to pregnancy [Document details about menstrual cycle before pregnancy including regularity and characteristics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Smear [Document most recent cervical smear test date and result, including HPV co-testing if done] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Gynaecology issues
[Document any ongoing or past gynaecological conditions including fibroids, endometriosis, ovarian cysts, pelvic inflammatory disease, or other structural or hormonal issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Abdo infxn/surgeries
[Document history of abdominal infections (e.g. TB abdomen, pelvic inflammatory disease) or surgeries including caesarean section, appendectomy, laparotomy/laparoscopy, bowel surgery or adhesions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications
[Document all current medications, including iron, folate, calcium supplements, multivitamins, antihypertensives, antidiabetics or any traditional or over-the-counter medicines used during pregnancy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies
[Document all allergies including to medications (e.g. penicillin), foods, latex or other allergens, with description of reactions (e.g. rash, anaphylaxis)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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 included 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.)
