Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Prenatal visit for a patient with pre-existing diabetes (type 1, type 2, or gestational diabetes)
Follow-up visit to monitor glycemic control and fetal well-being
II. History of Present Illness:
Type of diabetes (pre-existing or gestational)
Gestational age (weeks)
Current symptoms (if any) – nausea, vomiting, changes in blood sugar control
Frequency of self-monitoring of blood glucose (SMBG)
Dietary adherence
Medication adherence (insulin or oral medications)
III. Past Medical History:
Diabetes complications (retinopathy, neuropathy, nephropathy) – if applicable
Obstetric history (previous pregnancies, complications)
IV. Family History:
Diabetes in first-degree relatives
V. Social History:
Smoking, alcohol, or illicit drug use
Prenatal exercise habits
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Fundal height assessment (fetal growth)
Fetal heart rate monitoring (non-stress test or biophysical profile) – may be done at specific gestational ages
VII. Laboratory Studies (consider as appropriate):
Hemoglobin A1c (HbA1c): Assesses long-term glycemic control.
Fasting blood glucose: Monitors current blood sugar levels.
Urine ketones: May be checked if blood sugar levels are high.
Thyroid function tests (TSH): May be checked as abnormal thyroid function can affect blood sugar control.
VIII. Assessment:
Glycemic control based on SMBG results, HbA1c, and any other blood sugar checks.
Fetal well-being based on physical exam, fetal heart rate monitoring, and any concerns about fetal growth.
Risk of maternal and fetal complications associated with diabetes in pregnancy.
IX. Plan:
Management plan may include:
Dietary modifications: Registered dietitian consultation for a personalized diabetic meal plan.
Exercise recommendations: Regular physical activity tailored to pregnancy.
Medication adjustments: Insulin dose adjustments based on blood sugar monitoring may be needed.
Self-monitoring of blood glucose (SMBG): Establish a consistent SMBG schedule.
Prenatal education: Educate the patient on diabetes management during pregnancy and potential risks.
Fetal surveillance: Regular prenatal visits with fetal heart rate monitoring and additional tests (ultrasound) as needed.
X. Prognosis:
Discuss the prognosis based on the patient’s current glycemic control, adherence to treatment plan, and fetal well-being.
With good glycemic control and close monitoring, most pregnancies with diabetes can achieve positive outcomes.
XI. Notes:
Address the patient’s concerns and answer questions about diabetes management during pregnancy.
Provide emotional support and encouragement.
Coordinate care with other healthcare providers involved in the patient’s pregnancy (obstetrician, diabetes educator).
XII. Resources:
Consider providing patient education materials on diabetes in pregnancy from reputable sources (e.g., American Diabetes Association (ADA), American College of Obstetricians and Gynecologists (ACOG)).