Question

24 yo G2P1 presents to clinic with "no period for two months" and two positive pregnancy tests at home. She feels a little nauseated, bloated, and has some breast tenderness. History of irregular menses prior to having her child, but have been regular since the birth of her first child.

Medications: None

Allergies: NKDA

PMH: Depression, anxiety

Pregnancy history:

2014 - MAB

2015 Term Vaginal Delivery no complications.

No relevant family history

Social history: Smokes 3-5 cigarettes per day for multiple years, denies ETOH or drug use. Lives with fiance and children. Does not work. Hx domestic abuse with ex-husband, no current abuse.

UPT negative in office today.

In SOAP format:

1.     Subjective: Write out the subjective information you have. Write what other information you would want.

2.     Objective: Write out an objective assessment that you would expect to find. Include only the relevant systems.

3.     Assessment: What are your differential diagnoses? Include at least three. Write a rationale for each one.

4.     Plan: Based on the information provided, what would your plan be at this visit? Be sure to include relevant diagnostics, treatments, education, referrals, and follow up.

Answer 1

SOAP is a documentation method of writing the progress of the patient.It includes subjective ,objective ,assessment and plan.

Subjective	cheif complaints,history of present illness,review of systems,medication and allergies	No periods for two months,Nausea,bloating,breast tenderness ,history of complications ,anxiety,depression,menstrual history,last menstrual period,sexual history,
Objective	observable measurable data.it includes vital signs,physical examination,lab data,imaging test result	physical exmination,abdominal,per vaginal examination,posive pregnancy test by urine ssample
Assessment	interpretation of subjective and objective problems .includes differential diagnosis	pregnancy,hyperemesis,food poisoning,psedocyesis,uterine/ovarian cyst,ectopic
Plan	need for additional testing consultation	lmp and assessment of gestation,pregnancy confirmation,ultrasound abdominal or transvaginal,psychiatry consultations