General Obstetric Follow Up

Subjective:
Chief Complaint:
Routine antenatal follow-up.

History of Present Illness:
The transcript provided does not contain any specific details about the patient's symptoms, concerns, or updates regarding their condition prior to the visit. Therefore, no History of Present Illness can be constructed from the given information.

The Review of Systems:
Constitutional – no fever, chills, weight loss, weight gain, night sweats, fatigue, or weakness
Cardiovascular – no chest pain, heart palpitations, dizziness
Respiratory – no shortness of breath, no cough, no wheezing
Gastrointestinal – no nausea, vomiting, or constipation
Genito Urinary – no dysuria, hematuria, frequency, urgency
Neurological – no headaches, no vision changes

Obstetric History:
On examination, the symphysis-fundal height measured 33 centimeters. The fetal heart rate was 140 beats per minute. The fetus demonstrated cephalic presentation and was active on examination. The patient's weight was recorded as 100 kilograms.

Objective:
Vital Signs:
Blood pressure is 106/70 mmHg. Weight is 100 kilograms. Fundal height is 33 centimeters. Fetal heart rate is 140 beats per minute.

Physical Examination:
General – Appears well, alert, no acute distress
Cardiovascular – Heart rate regular, S1S2 normal, no murmurs
Respiratory – Lungs clear to auscultation bilaterally, no wheezes or crackles
Abdomen – Fundal height appropriate for gestational age, fetal heart tones present and within normal range, no tenderness

Assessment and Plan:
- Routine Antenatal Care (V22.2): Clara Bennett appeared clinically well. Blood pressure was 106/70 mmHg. Symphysis-fundal height was 33 centimeters. Fetal heart rate was 140 beats per minute. The fetus was active with cephalic presentation. Plan:
• Continue routine antenatal monitoring.
• Provided reassurance to the patient and indicated that a follow-up message and letter would be sent.

Problem:
Routine prenatal follow-up.