soap note and total of 5 questions
Hannah is 38 years old, G1P0, 32 weeks EGA and comes to you for her routine prenatal appointment. Her BP is 156/96 and her urine has 2+ protein. She complains of having a headache that will not go away and just not feeling “right” for the past 7 days. Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note. Subjective: What other relevant questions should you ask regarding the HPI? O- when did you started to experience the headaches? A couple weeks ago L- What side of your head is the pain located? In the front of my head both sides D- How long does the headache lasts? For a couple hours C- How does the headache feels? Throbbing, aching, pressure or pulsating? Pulsating A- What makes the headache better or worse? When I lay down in my bed the headaches tend to get worst. Tylenol usually helps R- Does the headache radiates to your neck or any other part of your head? No, it does not radiate T- At what time during the day do you experience the headaches? Usually in the afternoon S- Scale 0-10 what number will you give the headache? 7 · Have you hurt your head recently? No · Are you drinking enough water? · Any changes in your vision? No · Any changes in your mental status? No · Any recent seizure activity? No · Have you change anything in your diet? I have been craving a lot of food containing carbohydrates What other medical history questions should you ask? · History of hypertension? · History of heart problems in her family? · Recent hospitalization What other OB history questions should you ask? Objective: Describe the appropriate physical assessment that needs to be included in this visit. BMI Vision checks for (scotoma, papilledema, vascular spasms, arteriovenous nicking) Neuro assessment (headaches, CNS involvement, seizures) Abdomen RUQ pain (liver involvement) Musculoskeletal -Deep tendon reflex Skin assessment (bruising) Mouth (bleeding gums) Respiratory (lung sounds for pulmonary edema, SOB) Vascular- presence of worsening edema Explain what test(s) you will order and perform and discuss your rationale for ordering and performing each test. A CBC will be ordered in this case patient signs and symptoms suggest preeclampsia. Patients with preeclampsia usually have a platelet count of <100,000/microliter putting the patient at high risk of bleeding. Serum creatinine level, in patients with preeclampsia creatinine levels are >1.1mg/dl. Liver chemistry, elevated liver enzymes is usually seen in patients with this condition which can lead to other complications. Quantitative urinary protein. Fetal ultrasound to evaluate amniotic fluid volume and estimate fetal weight due to the high risk of oligohydramnios and fetal growth restrictions in patients with preeclampsia. If patients’ tests are negative for preeclampsia other test will be ordered depending on the patient presenting symptoms and objective data. Also, will like to include a chest x-ray if pulmonary edema is suspected. Assessment/ Diagnosis: What is your diagnosis? Mild to Moderate Preeclampsia (ICD-10: O14.0) Read More …