Desire for Pregnancy
Age: years old
Gender: female
HISTORY:
Presents for a desire for pregnancy
Planning a pregnancy in the next
Last check-up was ago
Current symptoms:
Gynecological history:
Last menstrual period: ago
Menstrual cycles: days,
G P A
Fertility concerns:
Contraception:
Last Pap smear: ago
STI risk factors:
Medication:
Over-the-counter supplements: , , , ,
Past medical history:
Family history: , ,
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Diet: , , , ,
Physical activity:
Weight: ,
Occupation:
Living with:
Domestic violence screening:
Labs:
Hb:
Creatinine:
HbA1c:
Fasting blood glucose:
Lipids: , Cholesterol: , LDL: , HDL: , Triglycerides:
TSH:
Chlamydia/Gonorrhea:
Syphilis:
HIV:
Hepatitis C:
HBsAg: , Anti-HBs:
Rubella IgG:
Varicella zoster IgG:
Vaccinations:
Influenza:
Covid:
Tdap:
HPV:
Hepatitis A:
Hepatitis B:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: weight: , height: cm, waist: cm, BMI:
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Breasts: , ,
Abdomen: , , ,
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: anovulation, polycystic ovary syndrome, thyroid disorders, hyperprolactinemia, male factor infertility (e.g., low sperm count, motility issues), tubal factor infertility (e.g., blocked fallopian tubes), uterine abnormalities (e.g., fibroids, polyps), endometriosis, age-related decline in fertility, lifestyle factors (e.g., smoking, excessive alcohol consumption), medication side effect (e.g., chemotherapy, anti-inflammatory drugs), unexplained infertility, genetic disorders, autoimmune disorders, sexually transmitted infections, cervical factor infertility, vaginal environment issues, coital problems, psychological factors/stress, environmental toxins and exposure
PLAN:
Investigations:
- Blood work: , , , , , , , , , ,
- Genetic carrier screening
- Pap smear
Treatments:
-
- Lifestyle modifications: , , , , ,
- Immunizations: , , ,
- Stop medications that are unsafe in pregnancy
- Dental care
Further care:
- Referral to obstetrician
- Referral to genetic counselor
- Follow-up in
- Return if no pregnancy after 6-12 months of trying
HISTORY: EXAM: ASSESSMENT: PLAN: