S.O.A.P. Note Template
Complaint
36 week OB appointment with complaints of daily hand swelling and a headache.
History of Present Illness
This is a 33 year old female presenting for her 36 week OB appointment. She has complaints of
daily hand swelling, having a headache three times last week and rating it a 7/10. Her
headaches are located in the bilateral temporal area. Also, noted her vision seemed off last
week, however, her eye doctor stated this can happen with pregnant women. She is having good
fetal movement. Is feeling some contractions occasionally.
Past Medical History
Patient has had chicken pox as a child. She denies any history of broken bones or surgeries. She
denies any allergies. She has received all vaccines as a child and as an adult. She has received
her TDAP in pregnancy and flu vaccines due to dates and time of year. Currently in this
pregnancy she has been getting some reflux and nausea but the nausea has gotten better since
the first trimester.
Current medications:
Prenatal vitamin: daily
Pepcid 20mg PO: BID
Zofran 4mg PO: TID
PRN
Family History
Reports negative family history.
Personal/Social History
She has some college education. Reports working at Chase bank part time. She is married and
this is her first child. She denies any alcohol use in pregnancy. Denies any drug use or smoking.
Denies doing any specific exercise routine, but tries to walk daily. She does not have a specific
diet.
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, Review of Systems (as applicable to CC)
• General: Visibly is swollen and seems unfomfortable.
• Hair, Skin, & Nails: Appropriate.
• Head: Reports headache bilaterally in temporal lobes.
• Neck:
• Eyes: Reports visual disturbances.
• Ears:
• Nose:
• Mouth & Throat:
• Cardiovascular: Denies any chest pain, palpiations, or feelings of a
racing heart.
• Respiratory: Denies any SOB, cough, or congestion.
• Breasts:
• Gastrointestinal:
• Musculoskeletal: Reports some carpal tunnel in bilateral hands.
• Peripheral: Bilaterally swollen hands 1+, bilateral lower extremeties
swollen 2+, pitting 1+. Normal pedal pulses. Reflexes 1+. No clonus.
• Neurological: A&O x4.
• Psychiatric: Appropriate.
Physical Examination (as applicable to CC/HPI)
• Vital signs: HR 88, BP 178/92, RR 20, Spo2 98%, Temp 98.7 F, Weight
215lb
• General Appearance: Well nourished, uncomfortable appearance,
swollen.
• HEENT: Headache present to bilateral temperal lobes. Pain 7/10.
• Neck: Midline and WDL.
• Chest: Lung sounds clear. Normal chest expansion.
• Cardiac: Heart rate and rhythm regular. NO murmer present.
• Abdomen: Audible bowel sounds, rounded, fundal height
appropriate for gestation, nontender, palpating mild
contractions occasionally.
• Genitourinary: Urine clear yellow. SVE 2/70/-3. Membranes intact.
• Skin: BUE swelling 1+, BLE swelling 2+ with 1+ pitting edema.
• Musculoskeletal: Positive tinel and phalens sign to bilateral wrists.
• Neurologic: A&O x4, Reflexes 1+, HA present, no clonus.
• Psychiatric: Appropriate.
Diagnostic Testing/Findings (if appropriate)
Send to Labor and Delivery for direct admit for induction of labor with PIH
workup.
CBC: Platelet count 150,000/microL,
WBC 15 CMP: Relatively normal.
UA-protein present (>2+)
Urine protein/creatinine ratio: 0.35
This study source was downloaded by 100000829878664 from CourseHero.com on 07-07-2022 02:33:34 GMT -05:00
https://www.coursehero.com/file/55884764/Week-3-soap-notedocx/
Complaint
36 week OB appointment with complaints of daily hand swelling and a headache.
History of Present Illness
This is a 33 year old female presenting for her 36 week OB appointment. She has complaints of
daily hand swelling, having a headache three times last week and rating it a 7/10. Her
headaches are located in the bilateral temporal area. Also, noted her vision seemed off last
week, however, her eye doctor stated this can happen with pregnant women. She is having good
fetal movement. Is feeling some contractions occasionally.
Past Medical History
Patient has had chicken pox as a child. She denies any history of broken bones or surgeries. She
denies any allergies. She has received all vaccines as a child and as an adult. She has received
her TDAP in pregnancy and flu vaccines due to dates and time of year. Currently in this
pregnancy she has been getting some reflux and nausea but the nausea has gotten better since
the first trimester.
Current medications:
Prenatal vitamin: daily
Pepcid 20mg PO: BID
Zofran 4mg PO: TID
PRN
Family History
Reports negative family history.
Personal/Social History
She has some college education. Reports working at Chase bank part time. She is married and
this is her first child. She denies any alcohol use in pregnancy. Denies any drug use or smoking.
Denies doing any specific exercise routine, but tries to walk daily. She does not have a specific
diet.
This study source was downloaded by 100000829878664 from CourseHero.com on 07-07-2022 02:33:34 GMT -05:00
https://www.coursehero.com/file/55884764/Week-3-soap-notedocx/
, Review of Systems (as applicable to CC)
• General: Visibly is swollen and seems unfomfortable.
• Hair, Skin, & Nails: Appropriate.
• Head: Reports headache bilaterally in temporal lobes.
• Neck:
• Eyes: Reports visual disturbances.
• Ears:
• Nose:
• Mouth & Throat:
• Cardiovascular: Denies any chest pain, palpiations, or feelings of a
racing heart.
• Respiratory: Denies any SOB, cough, or congestion.
• Breasts:
• Gastrointestinal:
• Musculoskeletal: Reports some carpal tunnel in bilateral hands.
• Peripheral: Bilaterally swollen hands 1+, bilateral lower extremeties
swollen 2+, pitting 1+. Normal pedal pulses. Reflexes 1+. No clonus.
• Neurological: A&O x4.
• Psychiatric: Appropriate.
Physical Examination (as applicable to CC/HPI)
• Vital signs: HR 88, BP 178/92, RR 20, Spo2 98%, Temp 98.7 F, Weight
215lb
• General Appearance: Well nourished, uncomfortable appearance,
swollen.
• HEENT: Headache present to bilateral temperal lobes. Pain 7/10.
• Neck: Midline and WDL.
• Chest: Lung sounds clear. Normal chest expansion.
• Cardiac: Heart rate and rhythm regular. NO murmer present.
• Abdomen: Audible bowel sounds, rounded, fundal height
appropriate for gestation, nontender, palpating mild
contractions occasionally.
• Genitourinary: Urine clear yellow. SVE 2/70/-3. Membranes intact.
• Skin: BUE swelling 1+, BLE swelling 2+ with 1+ pitting edema.
• Musculoskeletal: Positive tinel and phalens sign to bilateral wrists.
• Neurologic: A&O x4, Reflexes 1+, HA present, no clonus.
• Psychiatric: Appropriate.
Diagnostic Testing/Findings (if appropriate)
Send to Labor and Delivery for direct admit for induction of labor with PIH
workup.
CBC: Platelet count 150,000/microL,
WBC 15 CMP: Relatively normal.
UA-protein present (>2+)
Urine protein/creatinine ratio: 0.35
This study source was downloaded by 100000829878664 from CourseHero.com on 07-07-2022 02:33:34 GMT -05:00
https://www.coursehero.com/file/55884764/Week-3-soap-notedocx/
