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OB/GYN Soap Note

Student’s Name

Institution Affiliation

Course

Instructor

Date
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Patient Information:

J.G., 16-year-old female, Caucasian.

Subjective

CC: Nausea and Vomiting

HPI: Miss. J.G., a 16-year-old Caucasian female presents to the hospital complaining about

nausea and vomiting off and on over the past month. She also states that abdominal pain

accompanies the nausea and vomiting at times, it comes on quickly and quickly subsides. She

reports that the nausea and vomiting occur throughout the day, but mostly in the morning. J.G.

reports that she has been drinking a lot of water therefore does not feel that she is dehydrated.

She hasn’t had any weight changes and continues to participate in sports at school.

Current Medications: No medications.

Allergies: No known allergies.

Immunizations: Up to date.

PMHX: No chronic illnesses.

PSHX: No surgeries.

GYN HX: Para: 0, Gravida: 0, LMP: 1 month ago

Soc HX: 10th grade, participates in sports, no tobacco use.

Fam HX: Parents are in great health.

ROS:

General: Oriented, attentive, and cooperative. No acute pain, denies fever, night sweats,

headaches, changes in vision.

Skin: Intact, dry and warm. No noticeable lesions.

Neuro: No weakness, tingling or numbness noticed in extremities, no trouble with speech or

balance.

HEENT: Denies headaches, dizziness. Denies vision problems, no blurred /double vision, no

pain or drainage. No contact lenses or glasses. Denies earache, ringing in ears. Denies nasal

congestion, runny nose, nosebleeds. Denies sore throat, difficulty swallowing. Denies neck pain

or swelling.

Respiratory: No SOB, no coughing.

CV: No chest pain, no irregular heartbeat, no syncope.

GI: Reports nausea, vomiting and abdominal pain.

GU: Denies pain with urination, denies blood in urine.

Musculoskeletal: No joint pain, no back pain.

Heme: No bruising, or bleeding.

Psych: Denies depression, and SI/HI.

Objective

Physical Exam:

BP: 112/70; HR 74; RR 18; T: 98.7; Hgt: 5'6" (167.64 cm), 78th percentile; Wgt: 127 lbs (57.72

kg), 65th percentile; BMI: 20.5, 51st percentile (normal BMI) Staging: Tanner 5

General: No acute pain, appears well nourished.

HEENT: Head normocephalic with no sign of trauma or masses. Thick hair that is distributed

all through scalp. PERRLA, EOMs intact, eyes with no exudate, sclera white. Ear canal patent,

with no irritation or redness. Tympanic membranes clear, pearly gray, no discharge, no pain

noted. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair,
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no cavities noted. Neck full ROM, supple. Anterior and posterior cervical lymph nontender to

palpation. No lymphadenopathy.

Skin: intact. No bruising noted.

CV: S1/S2, RRR, no murmurs, no rubs or gallop heard.

Lungs: CTA bilaterally.

Abdomen: Non-distended, non-tender, Soft, BS present x 4, no masses or organomegaly present.

Musculoskeletal: Full ROM of extremities, no pain to extremities or back noted. Good strength

bilaterally. Normal Gait.

Neuro: Sensation intact bilateral upper and lower extremities, bilateral UE/LE strength 5/5

Diagnostic or Lab results:

CBC: WBC 6,300/mm3, Hgb 12.8 gm/dl, Hct 38.4%, RBC 4.6 million MCV 93 fl, MCHC 34

g/dl, RDW 13.8%, PLT 160,000 mcl

BMP: BUN 10 mg/dl, Creat. 0.8 mg/dl, Glucose 80, Potassium 2.8, Sodium 137, Chloride 99,

Calcium 9.0

UA: pH 7, SpGr 1.010, Leukocyte esterase negative, nitrites negative, negative glucose; negative

protein; negative ketones

Pregnancy Test: negative

UDS: positive THC

Assessment

 Differential Diagnosis:

o Amenorrhea, unspecified encounter for normal pregnancy supervision, first

Trimester.

o Polycystic ovarian disease

 Diagnosis: Encounter for normal pregnancy supervision, first trimester (Z34.81).

Plan

Plan:

1. Conducted breast examination today

2. Conducted Papanicolaou Smear today along with bimanual examination of ovaries and

uterus.

3. Performed urine tests (Urinalysis) – protein 2+. Ketone 4+.

4. Took Urine HCG today, which returned positive results.

5. Performed auscultation of lungs and heart, and carried out abdominal examination WNL.

6. Drew STD/STI Panel, Prenatal Panel with HIV, Sickle Cell Screen for lab confirmation

today.

7. Prescribed Phenergan 12.5 mg tablet Q12H PRN.

8. E-prescribed Prenatal Vitamin 1 table for daily intake.

9. During the next visit, I will plan for a dating ultrasound with ONIPS.

10. I will inform the patient about the outcomes of the laboratory work performed today.

11. I will do a follow-up within four weeks for OB/FU appointment.

12. I will do a follow-up within four weeks for a dating ultrasound, ONIPS.

Teaching:

1. First Trimester Education

Discussed with the patient about subjects ranging from what she should be eating, the

type of prenatal tests she ought to consider, the amount of weight she might gain, and

how she can ensure that the baby remains healthy. I also discussed with the patient about

the body changes she should expect during the 1st trimester. I informed her that during the
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1st trimester, her body will experience multiple changes. The body will release hormones

which will impact nearly all body organs (Schrager et al., 2021). The initial sign she will

be pregnant will be missing her periods. As the first few weeks go on, she might also start

experiencing stomach upset, tiredness, tender breasts, weight gain, headaches, mood

swings, vomiting, constipation, revulsion to some foods, and cravings for some foods

(Shah, 2020).

2. Prenatal Care Education

Discussed with the patients about getting prenatal care and maintaining her health, mental

health and rest, and the things she should avoid, including smoking, taking alcohol, use of

drugs, consuming dangerous foods, and participating in risky activities (Peahl & Howell,

2021). I informed her about the benefits of prenatal care from a doctor and ensuring that

her body gets all the necessary nutrients and vitamins. I alerted her that her body will go

through some crucial changes during the pregnancy because the body is the first home of

the baby, thus it is crucial to take good care of herself (Peahl et al., 2020). I informed her

that once she gets a positive pregnancy test, she should call her doctor and schedule her

first prenatal appointment. During the doctor’s visit, the doctor will take a complete

health history and carry out a full pelvic and physical examination (Aziz et al., 2020).

Also, the doctor will conduct ultrasound for pregnancy confirmation, a Pap test, blood

pressure, test HIV, STIs, and hepatitis. Also, I discussed with the patient about the

importance of taking prenatal vitamins, staying active, eating healthy foods, staying

hydrated, getting a flu shot, and getting sufficient sleep.

3. Toxoplasmosis Precautions
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I discussed with her the measures she should put in place to avoid contracting

toxoplasmosis. Informed her that pregnant women who contract toxoplasmosis could

pass the parasite to the unborn child, who could develop severe health issues. To avoid

being infected by the parasite, she should thus ensure she drinks clean water, she washes

vegetables and fruits, and she cooks meat thoroughly (Damar Çakırca et al., 2023). She

should also make sure she wears gloves while gardening or when she has any contact

with sand or soil since it may be contaminated with cat feces containing Toxoplasma.

Besides, she should always wash hands with water and soap after any contact with soil or

gardening.

4. Urine Dipstick Test Counselling

I discussed with the patient about performing urine dipstick during the pregnancy. This

test offers a rapid semi-quantitative evaluation of urinary features and is crucial in the

course of the pregnancy for screening for gestational diabetes, liver conditions,

dehydration, preeclampsia, infection. Informed the patient blood pressure should be

monitored at all prenatal visits and counselled her on warning symptoms of preeclampsia.

Also, informed her that weight is measured during all prenatal visits, and advised her on

optional weight gain.

5. Gestational Diabetes Teaching

We discussed the significance of maintaining low glycemic diet, constant physical

activity, and avoiding excess gestational weight during the pregnancy. I also encouraged

her to continually be taking higher-fiber proteins, carbohydrates, as well as, unsaturated

fats. Similarly, we talked about maternal macrosomia risk, including arrested or slowed

labor, cesarean delivery, operative vaginal delivery, postpartum hemorrhage, genital tract
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lacerations, and also uterine rapture (Johns et al., 2018). Lastly, we talked about fetal risk

of macrosomia such as respiratory problems, hypoglycemia, shoulder dystocia,

polycythemia, along with long-term conditions like heart disease, obesity, and

endocrine/metabolic disorders.

Reflection

The patient is a 16-year-old Caucasian female who presented to the clinic with complaints of

nausea and vomiting off and on over the past month accompanied with abdominal pain

sometimes. She was well-dressed and cheerful during the examination. Based on the GYN

assessment, it was confirmed that the patient was healthy without abnormal results in 1st

trimester. It was considered that the patient could be nine weeks pregnant. Discussed with the

patient about prenatal care, including visiting a doctor, the expected body changes. Informed her

of missing her periods, and changes in each body organ such as stomach upset, tiredness, tender

breasts, weight gain, headaches, mood swings, vomiting, constipation, revulsion to some foods,

and cravings for some foods. Also, I discussed with her about maintaining her health, mental

health and rest, and the things she should avoid, including smoking, taking alcohol, use of drugs,

consuming dangerous foods, and participating in risky activities. Furthermore, we had a

conversation about toxoplasmosis precautions, urine dipstick testing, and gestational diabetes. I

informed the patient that she would be contacted through telephone to notify her of the lab

results. Also, I will schedule a dating ultrasound during the next visit with ONIPS. The patient is

also scheduled to a follow-up appointment within four weeks for OB/FU visit with ONIPS.
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References

Aziz, A., Fuchs, K., Nhan-Chang, C. L., Zork, N., Friedman, A. M., & Simpson, L. L. (2020,

November). Adaptation of prenatal care and ultrasound. In Seminars in

Perinatology (Vol. 44, No. 7, p. 151278). WB Saunders.

Damar Çakırca, T., Can, İ. N., Deniz, M., Torun, A., Akçabay, Ç., & Güzelçiçek, A. (2023).

Toxoplasmosis: A Timeless Challenge for Pregnancy. Tropical Medicine and Infectious

Disease, 8(1), 63.

Johns, E. C., Denison, F. C., Norman, J. E., & Reynolds, R. M. (2018). Gestational diabetes

mellitus: mechanisms, treatment, and complications. Trends in Endocrinology &

Metabolism, 29(11), 743-754.

Peahl, A. F., & Howell, J. D. (2021). The evolution of prenatal care delivery guidelines in the

United States. American Journal of Obstetrics and Gynecology, 224(4), 339-347.

Peahl, A. F., Gourevitch, R. A., Luo, E. M., Fryer, K. E., Moniz, M. H., Dalton, V. K., ... &

Shah, N. (2020). Right-sizing prenatal care to meet patients' needs and improve maternity care

value. Obstetrics & Gynecology, 135(5), 1027-1037.

Schrager, N. L., Adrien, N., Werler, M. M., Parker, S. E., Van Bennekom, C., Mitchell, A. A., &

National Birth Defects Prevention Study. (2021). Trends in first‐trimester nausea and

vomiting of pregnancy and use of select treatments: Findings from the National Birth

Defects Prevention Study. Paediatric and perinatal epidemiology, 35(1), 57-64.