Pre-Conception Visit

Age: ‍ years old

Gender: female



HISTORY:

Presents for a desire for pregnancy

Planning a pregnancy in the next ‍ ‍monthsyears

Last check-up was ‍ ‍years ago



Current symptoms: ‍ ‍noneno changes in health



Gynecological history:

Last menstrual period: ‍ ‍daysweeksmonths ago

Menstrual cycles: ‍ days, ‍regularirregular

G‍01234 P‍01234 A‍01234

Fertility concerns: ‍none



Contraception: ‍yesno ‍oral contraceptives

Last Pap smear: ‍ ‍monthsyears ago

STI risk factors: ‍



Medication: ‍ ‍none

Over-the-counter supplements: ‍, ‍none, ‍folic acid, ‍prenatal vitamins, ‍vitamin D



Past medical history: ‍ ‍unremarkable

Family history: ‍unremarkable, ‍type 2 diabetes, ‍hereditary conditions



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss

Occupation: ‍

Living with: ‍

Domestic violence screening: ‍ ‍not an issue



Labs: ‍unremarkable

Hb: ‍ ‍normal

Creatinine: ‍ ‍normal

HbA1c: ‍ ‍normal

Fasting blood glucose: ‍ ‍normal

Lipids: ‍normal, Cholesterol: ‍, LDL: ‍, HDL: ‍, Triglycerides: ‍

TSH: ‍ ‍normal

Chlamydia/Gonorrhea: ‍positivenegative

Syphilis: ‍positivenegative

HIV: ‍positivenegative

Hepatitis C: ‍positivenegative

HBsAg: ‍positivenegativeunknown, Anti-HBs: ‍positivenegativeunknown

Rubella IgG: ‍positivenegativeunknown

Varicella zoster IgG: ‍positivenegativeunknown

‍



Vaccinations:

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated

Tdap: ‍up-to-dateincompleteunvaccinated

HPV: ‍up-to-dateincompleteunvaccinated

Hepatitis A: ‍up-to-dateincompleteunvaccinated

Hepatitis B: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Desire for pregnancy ‍likelysuspectedpossible

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: ‍CBC, ‍TSH, ‍Rubella immunity, ‍Varicella immunity, ‍Hepatitis B, ‍Hepatitis C, ‍HIV, ‍Syphilis, ‍HbA1c, ‍Fasting glucose, ‍Lipid profile

- Genetic carrier screening

- Pap smear

Treatments:

- ‍Prenatal vitamins

- Lifestyle modifications: ‍healthy diet, ‍regular exercise, ‍weight loss if BMI >25, ‍quit smoking, ‍limit alcohol, ‍reduce stress

- Immunizations: ‍MMR, ‍Varicella, ‍Tdap, ‍Influenza

- Stop medications that are unsafe in pregnancy

- Dental care

Further care:

- Referral to obstetrician

- Referral to genetic counselor

- Follow-up in ‍ ‍months

- Return if no pregnancy after 6-12 months of trying