Download Prenatal SOAP note 8/26/2012 Name: Jane Doe DOB: xx-xx

Prenatal SOAP note
8/26/2012
Name: Jane Doe
DOB: xx-xx-1986
Subjective:
CC: 10 week prenatal visit
HPI: 26 yo gravida 1 para 0-0-0-0 female presents to Women’s health clinic for 10 week
prenatal check-up. Patient notes recurrent nausea that occurs throughout the day, primarily
occurring in morning and meal times, ranging 2-3 episodes per day. Patient states that nausea has
lessened from last visit, but still notes sensitivity to odors and certain foods including fish.
Patient has been taking Reglan 5 MG TID for nausea and vomiting, with moderate symptom
relief and reduction in daily occurrence of nausea. Patient denies abdominal pain or cramping,
fetal movement, vaginal bleeding, indigestion, diarrhea, constipation, change in stool,
hematemesis, urinary frequency, urgency, hematuria, recent UTI. LMP 6/19/2012. EDD:
3/26/2013.
ROS:
General – Fatigue, 5 lb. weight gain. Denies fever, chills, night sweats.
HEENT- Denies headaches, change in vision, change in hearing, nasal discharge, sore throat.
Cardiac – Denies heart disease, history of heart murmur or palpitations, HTN, SOB or DOE. Last
EKG with no significant findings 4/12/2012.
Resp – Denies chest pain, SOB, wheeze, cough, bronchitis, pneumonia. No history of CXR.
GI – see HPI.
GU – see HPI.
Musc – Full ROM. Denies joint or muscle weakness or pain.
Vascular – Denies leg swelling, varicose veins, history of thrombi.
Neuro – Denies history of seizures, fainting.
Hematologic – Denies anemia, blood transfusions, blood diseases.
Endocrine – Denies DM, polyuria, polydipsia, thyroid disease.
Skin – Denies itch, rash, lesions.
Medications:
1.
Reglan 5 MG TID for nausea/vomiting
2.
Folic acid 0.4 MG daily for NTD prevention
3.
Fish oil 4 GM daily for childhood atopic dermatitis prevention.
a. Patient has been attempting to take recommended dosage daily, but having trouble
keeping supplement down due to fishy aftertaste. Patient hasn’t been able to take
fish oil for 2 weeks.
Allergies: NKDA.
PMH:
Patient Hospitalizations: None.
Immunizations: up to date (TDap 2009, Varicella booster 2007, Gardasil 2009)
Surgeries: None.
Family History:
PatientMother: HTN
Father: HTN, HLD, asthma
Patient’s husband (father of baby)Mother: No known medical conditions
Father: HTN, COPD
Social History:
Marital status: married.
Employed: Yes, bank teller.
Tobacco products: Denies ever smoking, nor smoke exposure at home. Husband does not smoke
either.
Alcohol: Patient previously drank 1-2 drinks per week, but has not consumed alcohol for 4
months.
Drugs: Denies any illicit drug use.
Sexual history: onset of sexual activity with males at age 20, # of partners 1, no previous
pregnancies, previously used condoms for contraception, denies history of STIs.
Objective:
Physical Examination
General – AAOx3, NAD.
VS – Ht 5’5.5”, Wt 145 lbs, T 98.7 F, BP 135/91, pulse 101, PO2 98% on room air.
HEENT – Normocephalic, white sclera, no conjunctival injection, no external ear trauma, nasal
septum midline, trachea midline.
Cardiac – No lifts or heaves noted on inspection/palpation, PMI unappreciated on inspection,
RRR, S1 and S2 identified on auscultation, no M/G/R appreciated on exam.
Resp – Symmetric chest rise/fall. No accessory muscle use on inspection. CTA B/L, no wheeze,
rales, rhonchi on auscultation.
GI – Round, mildly distended abdomen. Active bowel sounds x 4 quadrants. Tympanic
percussion sounds x 4 quadrants. Non-tender abdomen with palpation x 4 quadrants. No
hepatosplenomegaly appreciated on palpation.
Breast/Genital– Large sized breasts, pendulus, nipples symmetric, no discharge. Tender nipples,
no palpable masses or nipple discharge with palpation. Pap smear and rectal deferred at this time
upon patient’s request. Previous pap smear performed 7/22/2012 with no lesions, discharge,
negative for gonorrhea, chlamydia and no culture growth from vaginal swab. Uterine size
unappreciated on exam.
Extremities – no lower extremity edema, varicose veins, cyanosis or discoloration.
Skin – Warm, moist skin. No discoloration, rashes, lesions.
Lymphatics – No lymphadenopathy noted in preauricular, postauricular, occipital,
anterior/posterior cervical chain, submandibular, submental, supraclavicular, infraclavicular and
axillary regions.
Prenatal lab work:
Blood work 7/22/2012 –
Type and RH: A+
Rubella immune, VDRL nonreactive, HBsAg negative.
Urinalysis 8/26/2012 – negative for ketones, nitrates, protein, blood.
Ultrasound on 8/26/2012 – FHT 136 bpm, gestational sac identified in uterus.
Assessment:
Dx – 10 week gestation with secondary nausea from pregnancy.
Ddx of nausea:
1.
2.
3.
4.
Nausea and vomiting from pregnancy – patient’s symptoms most predominantly occur
in the mornings and susceptible to smells/foods which follows the pattern of pregnancy
induced nausea and vomiting caused by rising HCG levels. Patient denies feelings of
nausea/vomiting prior to pregnancy and symptoms are lessening as pregnancy
progresses. The rise and fall of nausea/vomiting follow the HCG rise and fall during
pregnancy.
Hyperemesis gravidarum – symptoms of this condition are excessive vomiting leading
to dehydration. While the patient has been naueaus and vomting, she has only 2-3
episodes per day and is able to keep fluids down. She has not complained of
concentrated urine or dizziness reflective of dehydration. Urinalysis did not show any
ketones indicative of dehydration.
GI obstruction – gastric or small bowel obstruction may cause vomiting, but usually
also includes abdominal pain and stool changes (diarrhea, constipation). Patient denied
any diarrhea or constipation, denied abdominal pain or discomfort.
GERD/Peptic ulcer- stomach irritation from excess acid or irritation from peptic ulcer
may cause nausea. Patient denies any discomfort in epigastric region, heartburn, acid
reflux, coughing or sore throat. Due to pregnancy, patient does have increased risk of
GERD from fetus pushing up against stomach, but the current size of uterus is not even
identifiable at pubic symphysis so very low risk it would cause pressure up to stomach.
Plan:
1. Medications
a. Reglan 5 MG TID – continue for symptoms of nausea/vomiting.
i. Side effects – headache, dizziness, insomnia, tardive dyskinesia.
b. Fish oil 4 GM daily – advised patient to try to continue to take supplement for
fetal development and childhood atopic dermatitis prevention.
c. Folic acid 0.4 MG daily – continue for neural tube defect prevention.
2. Education
a. Patient educated on safety and health risks for having baby around pets.
b. Patient advised not to empty/clean litter boxes during pregnancy to prevent risk
of toxoplasmosis infection.
c. Patient recommended to consider Quad-screen during 2nd trimester to detect
congenital anomalies including NTDs, Down syndrome.
i. Explained to patient that results of Quad-screen does not provide a diagnosis,
but screening tool to detect risk for certain congenital issues.
d. Patient educated on the importance of nutrition and exercise during pregnancy.
Expected weight gain to be between 25-35 lbs. by end of 3rd trimester. Patient
instructed to continue light exercises 3-4x/week, no heavy lifting or strenuous
workouts.
i. Diet should include more bland foods until nausea subsides. Avoid spicy
foods, fish, drinking caffeine, smoke exposure.
e. Discussed attending Lamaze labor classes offered within community to prepare
for first delivery later in pregnancy.
3. Follow up
a. Patient to follow up in 1 month for 20 week check-up.
i. Plan to perform another urinalysis at this visit to check for protein in urine
due to family history of HTN and risk of preeclampsia.
ii. Plan to perform ultrasound to check anatomy of fetus.
b. Patient advised to contact office if having abdominal cramping, vaginal bleeding,
significant vomiting or any other issues or concerns.
c. If patient has significant bleeding, go directly to emergency department.
Alyson Wattai, PA-S