[Patient name] Sarah Jones, 32, Teacher, works in a primary school. Followed by [Partner name] David Smith, 35, Architect, works for a large firm.
**AMH levels** 1.2 ng/mL
[Reason for patient visit, e.g., primary infertility/secondary infertility] Primary infertility
[Previous fertility treatment details, location, and doctor] None
[General medical diagnosis relevant to infertility or obstetrics] None
Past Medical History: Nil significant
Past Surgical History: Appendectomy at age 10
Mental Health History: No history of mental health issues
Family History: Mother with early menopause
Medications: Folic acid 400mcg daily
Past Obstetric and Gynaecology History:
G: 0
P: 0
[Pregnancy outcomes and complications] N/A
Menstrual Cycles: Regular, 28-day cycle, 5 days of bleeding
HMB: No
Dysmenorrhoea/Dyspareunia/Dyschezia: Mild dysmenorrhoea
PID/STI: No history
CST: 2022, normal
Contraception: Previously used combined oral contraceptive pill, stopped 6 months ago
Pelvic Ultrasound: Normal uterus and ovaries, AFC 10
Social History:
Home with [Who patient lives with] Partner
Work: Teacher
Smoking: Non-smoker
ETOH: Occasional social drinking
Weight: 65 kg
Height: 165 cm
BMI: 23.9
Ix: Female screening bloods, pelvic US completed.
Partner:
Partner: David Smith, 35, present
Healthy: No known medical conditions
Past Medical History: Nil significant
Past Surgical History: Nil significant
Mental Health History: No history of mental health issues
Family History: Nil significant
Medications: Nil
Previous Pregnancies: None
Non-smoker
ETOH: Occasional social drinking
No sexual dysfunction
No mumps/trauma to testes
MSB: Normal
SA: Normal
Karyotype: Not discussed
Expanded GCS: Not discussed
[Partner investigations discussed] Semen analysis discussed and planned.
Discussion:
Discussed the results of the initial investigations. Explained the implications of the AMH level and the importance of further investigations, including a semen analysis for the partner. Discussed lifestyle factors and the importance of a healthy weight and diet. Discussed the possibility of ovulation induction and IUI.
[#] Genetic carrier screening and costing discussed
[#] Options discussed: Ovulation induction, IUI, IVF. Benefits, risks, and success rates of each discussed.
Plan:
Arrange semen analysis for partner. Review results in 2 weeks. Discuss further treatment options based on results. Follow-up appointment scheduled for 15 November 2024.
[Patient name], [age], [occupation], [general information about work] followed by [Partner name], [age], [occupation], [general information about work]
**AMH levels** (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Reason for patient visit, e.g., primary infertility/secondary infertility] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous fertility treatment details, location, and doctor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[General medical diagnosis relevant to infertility or obstetrics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History: [Patient's medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Surgical History: [Patient's surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mental Health History: [Patient's mental health history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History: [Patient's family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications: [Patient's medications and doses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Obstetric and Gynaecology History:
G: [Number of pregnancies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
P: [Number of babies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Pregnancy outcomes and complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Menstrual Cycles: [Cycle regularity, days of bleeding, average cycle length] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HMB: [Heavy menstrual bleeding] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Dysmenorrhoea/Dyspareunia/Dyschezia: [Symptoms with menstrual cycle] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PID/STI: [History of sexually acquired infections] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
CST: [Date of last cervical screening test and result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Contraception: [Current contraception and usage] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pelvic Ultrasound: [Details of scan, findings, AFC] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
Home with [Who patient lives with] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Work: [Patient's occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Smoking: [Smoking or vaping status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ETOH: [Alcohol consumption] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Weight: [Patient's weight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Height: [Patient's height] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
BMI: [Patient's BMI] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Ix: [Patient investigations, including female screening bloods, karyotype, pelvic US] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Partner:
Partner: [Partner's name and age, presence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Healthy: [Partner's medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History: [Partner's medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Surgical History: [Partner's surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mental Health History: [Partner's mental health history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History: [Partner's family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications: [Partner's medications and doses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous Pregnancies: [Details of previous pregnancies, partner, treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Non-smoker (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ETOH: [Alcohol consumption] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
No sexual dysfunction (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
No mumps/trauma to testes (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MSB: [Status of MSB] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SA: [Status of SA] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Karyotype: [Status of karyotype] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Expanded GCS: [Outcome or discussion of implications and cost] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Partner investigations discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discussion:
[Topics/issues discussed and summary] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[#] Genetic carrier screening and costing discussed (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[#] Options discussed: [Interventions, benefits, pros and cons, success rates, complications, risks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Plan discussed at the end of the consult, including ongoing review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)