Week 6 Soap Note Sarah Sanchez South University Online Dr. Murphy NSG 6430 January 15, 2025

SOAP NOTE Name: P.M. Date: 01/14/20 Time: 1200 Age: 35 Sex: Female SUBJECTIVE CC: “New pregnancy” established OB patient HPI: P.M. is a 35-year-old, G4P1 that is 13 weeks and 3 days based on last menstrual period. Patient is here in the office today for her first OB visit for a new pregnancy. The patient is sure of her LMP. Today the patient is also due for her pap smear, and pelvic examination. She reports fatigue, increased hunger, breast pain, tenderness, and back pain. Denies bleeding, leaking or cramping. Patient had her first pelvic ultrasound in first trimester on 12.8.2020. The findings were single, live IUP of 8 weeks and 4 days. It also showed subchorionic hematoma, probable anterior wall fibroid and right ovarian cyst mass measuring 2.5cm. She reports normal menstrual cycles, no abnormal bleeding in pregnancy. PMH Allergies: Penicillin Medication Intolerances: Denies Chronic Illnesses/Major traumas Headaches Hospitalizations/Surgeries G4P1 None NSVD 2008-Male, 6 Ibs Family History Mother- alive, hypertension, thyroid disorder, CVA Maternal Aunt- thyroid cancer Father- unknown Social History Denies smoking, alcohol Lives with Husband and son ROS General Patient appears clean, well-dressed, happy, and excited for pregnancy, with some fatigue at times. Cardiovascular Denies chest pain, claudication, irregular heartbeat, orthopnea, palpitations and shortness of breath. Skin Denies rash, lumps, moles. Respiratory Denies cough, shortness of breath, wheezing hemoptysis, clubbing of the fingers or sputum production.