Week 4
Skin Comprehensive SOAP Note
Patient Initials: MS Age: 27 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): Irregularly shaped bands and on abdominal area and itchy bumps on
upper and lower extremities
History of Present Illness (HPI): Melissa Sholts is a 27-year-old white female G1P0 35 weeks
gestation who presents to OB triage today with a complaint of itchy skin on upper and lower
extremities and dark irregular bands on the abdominal area. Patient reports that she started to
notice the dark bands on her abdomen 2 weeks ago and that they are getting darker in color and
raised. Per patient, last week she developed itchiness and small pink pimple-like spots in the
stretch marks and spread to her upper and lower extremities a week ago. “Since last week I am
having a hard time sleeping due to itchiness and I started to take over the counter Benadryl 25
mg before bed, but it does not help much”. Patient denies any history of stretch marks in the past.
Medications:
Prenatal vitamins
Benadryl 25mg before bed
Allergies:
Denies any allergies to medications, food, environmental
Past Medical History (PMH):
Denies any chronic illness
Past Surgical History (PSH):
Appendectomy as a child at 5 years old
Sexual/Reproductive History:
Heterosexual
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, Personal/Social History:
Married with no children, works as a manager at Jewel Osco. Patient leaves in suburbs with her
husband where they own their home and financially stable. Patient denies any history of cigarette
smoking, illicit drug use or marijuana use. Patient reports that she used to have a drink or two on
occasion before she got pregnant. Patient states that she feels safe at home and denies any type of
abuse. Patient states that she has a good support system and that both of her sisters have children
and that they are there to help out with her newborn baby.
Health Maintenance:
Patient reports seeing her primary care physician annually, and a Gynecologist throughout her
pregnancy. Per patient she has healthcare insurance from her job and that she does need any
supplemental resources. Patient states that she is eating a well-balanced diet. Patient repots that
she walks and stands a lot at her job.
Immunization History:
Patient reports that she had all her childhood vaccinations. Patient states that she got her Tdap
vaccine at 30 weeks gestation. Patient denies of getting a flu vaccine this year, but had it last year
in October.
Significant Family History:
Patient is the youngest born in a family of 3. Per patient, her older sister had a history of
cholestasis with her baby and that she had to be medically induced because of that. Patient
reports that her both parents are alive and denies them having any medical issues.
Review of Systems:
General: 20 lb. weight gain during pregnancy, no history of fevers, body malaise, chills, night
sweats, or pain.
HEENT:
No history of headaches, head traumas, or loss of consciousness. No changes in vision or
hearing, does not wear glasses or hearing aids. No history of blurred vision, hearing loss, or ear
pain. No history of nose bleeds or loss of smell. No history of a soar throat, difficulty
swallowing, or changes in voice. No history of toothaches, gum bleeding or difficulty chewing.
Denies any neck pain.
Respiratory: No history of wheezing, cough, sputum production, chest pain, or difficulty
breathing.
Cardiovascular/Peripheral Vascular: No history of chest pain, palpitations, difficulty
breathing, or varicose veins. Patient reports swallowing of her feet during pregnancy.
Gastrointestinal: Patient denies history of constipation, diarrhea, nausea, vomiting, or
abdominal pain.
© 2021 Walden University
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Skin Comprehensive SOAP Note
Patient Initials: MS Age: 27 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): Irregularly shaped bands and on abdominal area and itchy bumps on
upper and lower extremities
History of Present Illness (HPI): Melissa Sholts is a 27-year-old white female G1P0 35 weeks
gestation who presents to OB triage today with a complaint of itchy skin on upper and lower
extremities and dark irregular bands on the abdominal area. Patient reports that she started to
notice the dark bands on her abdomen 2 weeks ago and that they are getting darker in color and
raised. Per patient, last week she developed itchiness and small pink pimple-like spots in the
stretch marks and spread to her upper and lower extremities a week ago. “Since last week I am
having a hard time sleeping due to itchiness and I started to take over the counter Benadryl 25
mg before bed, but it does not help much”. Patient denies any history of stretch marks in the past.
Medications:
Prenatal vitamins
Benadryl 25mg before bed
Allergies:
Denies any allergies to medications, food, environmental
Past Medical History (PMH):
Denies any chronic illness
Past Surgical History (PSH):
Appendectomy as a child at 5 years old
Sexual/Reproductive History:
Heterosexual
© 2021 Walden University
This study source was downloaded by 100000843596919 from CourseHero.com on 03-31-2022 05:17:39 GMT -05:00
Page 1 of 5
https://www.coursehero.com/file/110840201/Stretch-marks-6512docx/
, Personal/Social History:
Married with no children, works as a manager at Jewel Osco. Patient leaves in suburbs with her
husband where they own their home and financially stable. Patient denies any history of cigarette
smoking, illicit drug use or marijuana use. Patient reports that she used to have a drink or two on
occasion before she got pregnant. Patient states that she feels safe at home and denies any type of
abuse. Patient states that she has a good support system and that both of her sisters have children
and that they are there to help out with her newborn baby.
Health Maintenance:
Patient reports seeing her primary care physician annually, and a Gynecologist throughout her
pregnancy. Per patient she has healthcare insurance from her job and that she does need any
supplemental resources. Patient states that she is eating a well-balanced diet. Patient repots that
she walks and stands a lot at her job.
Immunization History:
Patient reports that she had all her childhood vaccinations. Patient states that she got her Tdap
vaccine at 30 weeks gestation. Patient denies of getting a flu vaccine this year, but had it last year
in October.
Significant Family History:
Patient is the youngest born in a family of 3. Per patient, her older sister had a history of
cholestasis with her baby and that she had to be medically induced because of that. Patient
reports that her both parents are alive and denies them having any medical issues.
Review of Systems:
General: 20 lb. weight gain during pregnancy, no history of fevers, body malaise, chills, night
sweats, or pain.
HEENT:
No history of headaches, head traumas, or loss of consciousness. No changes in vision or
hearing, does not wear glasses or hearing aids. No history of blurred vision, hearing loss, or ear
pain. No history of nose bleeds or loss of smell. No history of a soar throat, difficulty
swallowing, or changes in voice. No history of toothaches, gum bleeding or difficulty chewing.
Denies any neck pain.
Respiratory: No history of wheezing, cough, sputum production, chest pain, or difficulty
breathing.
Cardiovascular/Peripheral Vascular: No history of chest pain, palpitations, difficulty
breathing, or varicose veins. Patient reports swallowing of her feet during pregnancy.
Gastrointestinal: Patient denies history of constipation, diarrhea, nausea, vomiting, or
abdominal pain.
© 2021 Walden University
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