SOAP NOTE FIVE
SUBJECTIVE
Ms. JS is a 20 year-old Hispanic female who presented to the women’s health clinic on June 21, 2013 for her first prenatal care.
History of Present Illness & Analysis of Symptom
Patient is G1 P0, currently 5 weeks + 3 days pregnant by LMP 5/14/2013. Had (+) home pregnancy test 2 days ago. Pt denies any nausea, reports mild breast tenderness. No vaginal bleeding or fluid. Reports large amount of yellow-white vaginal discharge, without odor, requiring that pt wears pad. Discharge began 3-4 weeks ago, with some “inside” pain noted during sexual intercourse. No itching or burning. No change in d/c after using Monistat at home. Pt denies any previous discharge.
Current Health Status
Pt has NKDA and is not currently taking any medications. Patient up to date with immunizations, except TdaP. Denies EtOH, tobacco, recreational drugs, or caffeine. Last physical exam 2 years ago, has never had Pap. Does not perform SBE. Reports eating good diet, with fresh produce, walks daily 20 min for exercise.
Past Medical History
Pt reports good general health and denies any previous major illness, injuries, blood transfusions, or hospitalizations. Reports usual childhood illnesses, including URIs 1-2X/ year. Able to perform own ADLs.
Social History
Pt lives with parents in local community. Pt works as cashier, shifts no more than 6h. Applied for WIC and Medicaid benefits during pregnancy. Has been in monogamous relationship w/ current partner x 3 mos. Denies abusive environment.
Family History
Pt’s mother has hx of HTN. Pt’s maternal GF has hx of adult-onset DM. Unable to recall any other familial illnesses. No recent ill contacts.
Review of Systems
General: Patient denies fever, weight loss, fatigue, or poor appetite. Diet: Reports regular diet, including fruits/vegetables. HEENT: Denies current or recent cough, coryza, nasal
discharge, hearing problems, or ear pain CV: Denies palpitations, or DOE Resp: No SOB, cough, or congestion. GI: Denies N/V/C/D. OB: G1P0, LMP 5/14/2013. Condoms used at time of conception. Regular periods every 28 days w/ “medium” 4 day flow. GU: Denies frequency,
SOAP NOTE FIVESUBJECTIVEMs. JS is a 20 year-old Hispanic female who presented to the women’s health clinic on June 21, 2013 for her first prenatal care.History of Present Illness & Analysis of SymptomPatient is G1 P0, currently 5 weeks + 3 days pregnant by LMP 5/14/2013. Had (+) home pregnancy test 2 days ago. Pt denies any nausea, reports mild breast tenderness. No vaginal bleeding or fluid. Reports large amount of yellow-white vaginal discharge, without odor, requiring that pt wears pad. Discharge began 3-4 weeks ago, with some “inside” pain noted during sexual intercourse. No itching or burning. No change in d/c after using Monistat at home. Pt denies any previous discharge.Current Health StatusPt has NKDA and is not currently taking any medications. Patient up to date with immunizations, except TdaP. Denies EtOH, tobacco, recreational drugs, or caffeine. Last physical exam 2 years ago, has never had Pap. Does not perform SBE. Reports eating good diet, with fresh produce, walks daily 20 min for exercise.Past Medical HistoryPt reports good general health and denies any previous major illness, injuries, blood transfusions, or hospitalizations. Reports usual childhood illnesses, including URIs 1-2X/ year. Able to perform own ADLs.Social HistoryPt lives with parents in local community. Pt works as cashier, shifts no more than 6h. Applied for WIC and Medicaid benefits during pregnancy. Has been in monogamous relationship w/ current partner x 3 mos. Denies abusive environment.Family HistoryPt’s mother has hx of HTN. Pt’s maternal GF has hx of adult-onset DM. Unable to recall any other familial illnesses. No recent ill contacts.Review of SystemsGeneral: Patient denies fever, weight loss, fatigue, or poor appetite. Diet: Reports regular diet, including fruits/vegetables. HEENT: Denies current or recent cough, coryza, nasaldischarge, hearing problems, or ear pain CV: Denies palpitations, or DOE Resp: No SOB, cough, or congestion. GI: Denies N/V/C/D. OB: G1P0, LMP 5/14/2013. Condoms used at time of conception. Regular periods every 28 days w/ “medium” 4 day flow. GU: Denies frequency,
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