09/18/2023
OBGYN SOAP Notes Prenatal SOAP Note:
Chief Complaint: The patient is a 30-year-old G2P1 at 28 weeks of gestation who presents for her routine prenatal check-up.
HPI:
Patient is a 30-year-old female with no pertinent medical history who presents for her biweekly prenatal appointment. Patient states that she has been doing well with her pregnancy and denies any current complaints. The patient states she has been eating a balanced diet as well as sleeping 7-8 hours per night. The patient reports occasional fatigue and mild lower back discomfort but otherwise feels well. She notes regular fetal movements. Patient confirms she is taking a prenatal vitamin with iron daily. Denies any signs of vaginal bleeding, contractions, or leakage of amniotic fluid. Denies any vaginal stinging, burning, or itching.
Review of Systems:
General: Mild fatigue. Denies any weakness, fever, chills, and night sweats.
Skin: No rashes, itching, or unusual pigmentation.
Head, Eyes, Ears, Nose, Throat (HEENT): No headaches, blurred vision, or hearing loss. No nasal congestion or sore throat.
Cardiovascular: No chest pain, palpitations, or edema. No history of heart disease.
Respiratory: No cough, shortness of breath, or wheezing. Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, or constipation. No changes in appetite or weight.
Genitourinary: No dysuria, hematuria, or urinary frequency. No changes in urinary habits.
Musculoskeletal: Moderate back pain. Denies muscle weakness, or limited range of motion. No history of arthritis or musculoskeletal disorders.
Neurological: No headaches, seizures, numbness, or weakness. Psychiatric: No depression, anxiety, or mood disturbances. Endocrine: No excessive thirst, hunger, or urination. No heat or cold intolerance.
Hematologic/Lymphatic : No easy bruising or bleeding. No swollen lymph nodes. PMH: Denies any pertinent past medical history. Allergies: NKDA. No known allergies to medications or environmental allergens. No history of autoimmune diseases.
Family Hx: Diabetes, Mother (Status: alive) Hypertension, Father (Status: alive)
Surgical Hx: Wisdom teeth removed, 2012. Immunizations: Patient is up to date on all immunizations. Medications: Chewable Prenatal Vitamin PO daily with 800 mcg of folic acid
Objective:
Physical Exam: Vital Signs:
Blood pressure: 123/75 mm Hg
Pulse: 80 bpm
Respiratory Rate: 16 bpm
Temperature: 98.6°F (36.9°C)
Weight: 154 lb (Last visit: 151 lb)
General: Well nourished, no acute distress. Cardiovascular Assessment: Heart sounds are regular with no murmurs or abnormal rhythms. No signs of peripheral edema. Varicose veins not observed.
Fetal heart rate: 140 bpm. Respiratory Examination: Respiratory effort is normal. Lung sounds are clear to
auscultation.
Abdomen: Soft and non-tender. Uterus is palpable just above the umbilicus and is
soft with no tenderness. No uterine contractions are palpated. Fetal movements are noted during examination. Fetal presentation is cephalic.
Fundal height: 28cm (Consistent with gestational age) Fetal heart rate: 140 bpm. Pelvic Exam: External genitalia appears normal with no signs of infection or lesions. Speculum examination of the cervix shows it is closed, pink, and no abnormal discharge is noted. No cervical dilation or effacement noted at this time.
No cervical or vaginal tenderness. No vaginal bleeding or discharge observed.
