SOAP Exemplar

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School

Howard University *

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Course

605

Subject

Medicine

Date

Apr 3, 2024

Type

pdf

Pages

3

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Report
OSCE SOAP Identifying Information: L.B., 26-year-old Caucasian female, she/her SUBJECTIVE: Chief Complaint: “here for prenatal visit” History of Present Illness: Patient is a 26-year-old female G2P0 presenting for her 26-week OB visit with an estimated due date of 10/3/2023. She reports no complaints since her last office visit. Reports good fetal movement. Denies vaginal bleeding or abnormal vaginal discharge. Medications: Prenatal vitamin Allergies: Shellfish (hives) Past Medical History: childhood asthma (no current inhaler use), PCOS, overweight (BMI 25.4). Surgical history: appendectomy (2012), no history of reaction to anesthesia OBGYN History: G2P0010. Uncomplicated medical abortion. Last pap at first OB visit was normal and denies a history of abnormal pap smears. Current male partner Suneel- boyfriend of 2 years. Social History: Switched jobs from a flight attendant to a customer service agent working at home. Reports improved quality of life with job change. Lives with her boyfriend in an apartment. Has support from Suneel regarding the pregnancy. Reports taking 2 walks a day for 10 minutes each. Reports frequently eating out and overindulging in food due to baby showers and parties. Drinks water throughout the day and denies drinking other beverages. Reports having 2 sips of wine every night for sleep aid. History of smoking 4 cigarettes per day but decreased to 1 cigarette a day. Denies any recreational drug use. Family Medical History: Mother has hypertension. Father had melanoma. Denies family history of DM, dyslipidemia, heart disease, mental health concerns or CVA. Review of Systems: General- Denies fatigue, fever or night sweats. Reports insomnia HEENT- Denies congestion, sore throat, vision changes, or headaches Cardiovascular- Denies chest pain, palpitations, or dyspnea Respiratory- Denies shortness of breath or chronic cough Gastrointestinal- Denies any abdominal pain, nausea, emesis, constipation or diarrhea Genital- Denies vaginal itching, vaginal bleeding, or abnormal discharge Urinary- Denies dysuria or burning. Reports frequency throughout pregnancy OBJECTIVE: Vital Signs: BP-129/86, Weight-164 (pre-pregnancy: 130) General: A+O x4, appears comfortable, normal mood and affect
Head: Normocephalic, no obvious abnormalities or lesions Extremities : No visible edema or varicosities OB Results: +FM, FHR: 150, Fundal Height 29cm LAB RESULTS: - Blood type: A - Rubella immune - H/H: 12.1/36 - G/C: negative, HIV 1+2: negative, RPR: non-reactive - Harmony screen: negative (do not disclose sex) - 1-hr GTT: 149 - Urine: trace ASSESSMENT and PLAN: 1) Supervision of normal pregnancy, second trimester (Z34.92) - Reviewed lab results with patient (negative STI screen, H+H WNL, UC- +GBS, ABNORMAL 1hr GTT) - Order Rh type - Reviewed negative genetic screening (Do not reveal sex) - Reviewed with patient that she should be monitoring for fetal movement - Reviewed FHR and expected FHR in pregnancy - Reviewed BP WNL and watching for BP over 140/90 - Educated patient on reducing or stopping daily alcohol intake--> recommend no alcohol during pregnancy o Educated patient on other ways to manage insomnia--> melatonin or tylenol PM if that is not working o Educated patient on sleep hygiene: dark room, cold, quiet - Follow up for next prenatal visit in 2 weeks. You can expect to come in every 2 weeks until 36 weeks and then every week until 41 weeks - Reviewed expectations for next appointment: will offer Tdap (reviewed reasons for vaccination re protection for baby), Rhogam if Rh negative (reviewed what Rh negative means in pregnancy re bleeding and to let future providers know her status) 2) Excess Weight Gain in Pregnancy, second trimester (O26.02) - Reviewed weight gain goal during pregnancy of 15-25 lbs and currently has a weight gain of 34 lbs - Educated patient on expected fundal height correlating to the gestational age--> patient is measuring slightly ahead for gestational age - Nutritional education (Z71.3)- o Recommend patient to focusing on eating lean protein, fruits and vegetables, and complex carbohydrates o Continue to drink water and stay hydrated - Reviewed activity goals of 30 minutes per day--> patient can extend walk time - Will continue to monitor weight at each visit
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