Dr. C obstetrical consult Template

OVERALL_INSTRUCTIONS

Chief Complaint

Prenatal, delivery, and postpartum care consultation.

Template

Dr. Susan Chow Family Medicine with Obstetrics #300-1133 Lonsdale Avenue North Vancouver, BC V7M 2H4 P: 604-987-2217 F: 604-988-8193 Dear Dr. [Name of Referring Family Physician/Primary Care Provider], Thank you for referring [Name of Patient] to our office for prenatal, delivery and postpartum care. She is a G[Gravida] T[Term] P[Preterm] A[Abortions] L[Living] at [Number of Weeks] weeks + [Number of Days] days with a LNMP of [DD MMM YYYY] and a due date of [DD MMM YYYY]. GYNECOLOGIC HISTORY: [Insert Gynecologic History] MEDICAL HISTORY: [Insert Medical History] SURGICAL HISTORY: [Insert Surgical History] PSYCHIATRIC HISTORY: [Insert Psychiatric History] SOCIAL HISTORY: [Insert Social History] FAMILY HISTORY: [Insert Family History] MEDICATIONS: Prenatal vitamin [Insert as a list with dashes Additional Medications if applicable] ALLERGIES: [Insert Allergies if present, omit section if no allergies] LAB INVESTIGATIONS: The patient has been given a requisition for the tests not yet reported. - Hemoglobin: [Insert Value] g/L - Rubella titre: [Insert Value] - HIV: [Insert Value] - Syphilis: [Insert Value] - HBsAg: [Insert Value] - Gonorrhea: [Insert Value] - Chlamydia: [Insert Value] - Urine C&S: [Insert Value] - Fasting glucose: [Insert Value] - Hep C: [Insert Value] - Blood group: [Insert Value] - TSH: [Insert Value] - Ferritin: [Insert Value] - HSV: [Insert Value] - VZV: [Insert Value] - SIPS/NIPT: [Insert Value] ULTRASOUND INVESTIGATIONS: [Insert Ultrasound Findings] CLINICAL EXAMINATION: - Weight: [Insert Value] kg - Height: [Insert Value] cm - BMI: [Insert Value] - Blood pressure: [Insert Value] - Heart rate: [Insert Value] bpm - Urinalysis: [Insert Value] - SFH: [Insert Value] cm - FHR: [Insert Value] bpm - HEENT: [if no concerns insert "PERRLA, normal EOM, fundi-clear disc margins, TM's-clear, pharynx-clear, normal thyroid, no nodes", if any issues present, insert relevant findings] - Chest: [if no concerns insert "clear", if any issues present, insert relevant findings] - CVS: [if no concerns insert "normal heart sounds, no murmur, no bruit, femoral and pedal pulses palpable", if any issues present, insert relevant findings] - Breast: [if no concerns insert "no axillary node, no masses, nipples everted", if any issues present, insert relevant findings] - Abdomen: [if no concerns insert "normal bowel sounds, normal LKKS, no masses, non-tender, no renal or femoral bruits", if any issues present, insert relevant findings] - MSK: [if no concerns insert "spine-no kyphosis, no scoliosis, hips-normal pain free range of motion", if any issues present, insert relevant findings] - GU: [ if no concerns insert "normal vulva, vagina and cervix, no abnormalities uterus or adnexae" if any issues present, insert relevant findings] - Rectal: [ if no concerns insert "no hemorrhoids, no masses", if any issues present, insert relevant findings] - Neuro: [ if no concerns insert "DTR present and equal bilaterally, no clonus, plantar responses down going", if any issues present, insert relevant findings] - Integ: [ if no concerns insert "no suspicious lesions", if any issues present, insert relevant findings] MENSTRUAL CYCLE PRIOR TO PREGNANCY: Regular/irregular every [Insert Number] days, lasting [Insert Number] days, light/normal/heavy blood loss SEXUAL FUNCTION: [if no concerns insert "Normal function", if any issues present, insert relevant findings] PSYCH: [ If no concerns insert "No psychological or psychiatric mental health concerns", if any issues present, insert relevant findings] POINT OF CARE ULTRASOUND FINDINGS: [Insert Findings] ASSESSMENT AND PLAN: We will be sending your patient for all the appropriate standard tests in the recommended time frame and any required tests and interventions as her pregnancy progresses. [Name of Patient] is hoping for a vaginal delivery and is aiming to breastfeed. You will be copied on my hospital admission and discharge notes. Six weeks post delivery we will return the patient to your care and will forward you the summary antenatal sheet along with my post delivery encounter notes for both mother and baby. With appreciation for your referral, Susan Chow, MD