NURSING 442 Initial OB soap note
Initial OB SOAP note
ID info: 21 year old WF
CC: OB physical
Allergies: Iodine, shellfish
HPI: Unplanned pregnancy for this G1 P0000 at 9 5/7 wks by LMP, confirmed
by transvaginal ultrasound. No complaints, except feels slightly tired. No
nausea/vomiting. No vaginal spotting/bleeding, abdominal pain or
cramping. Was ambivalent about pregnancy at first, “I’m okay with it
now”. FOB is supportive, as is her mother and sister.
Menstrual: LMP 12/25/2005, regular timing. Menarche: 12 yo, reg. menses q 26-28
days x 4-5days, mild dysmenorhea.
Sexual hx: Monogamous with steady boyfriend of 2 years, 4 lifetime partners, all
male. h/o Chlamydia 2 yrs ago, rx;d. This boyfriend without known STIs,
never tested. Describes sexual activity as ‘good’, though last month she
has been too tired for it. Was using condoms until about 6 months ago,
when switched to calendar method.
PMH/SH: Migraine headaches. Tubes in ears, T and A during childhood.
Psychosocial: Non-smoker. Denies illicit drug use. Social alcohol prior to positive
pregnancy test 1 mos ago, approx 1 drink/week. Completed 2 year
college. Denies emotional/physical abuse by partner. Pt is RN-some
exposure to infectious diseases and X-ray. Minimal exercise (30min
weekly). Lives with boyfriend in apartment. 1 cat.