Exam (elaborations)
NURSING 442 Initial OB soap note
Initial OB SOAP note date ID info: 21 year old WF CC: OB physical Allergies: Iodine, shellfish Subjective: 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.
