Week 11 SOAP note ob-gyn
Week 11 SOAP NOTE
Name: K.J Age: 22 Gender: Female Ethnicity: Caucasian
Subjective
Chief Complaint: "Abdominal pain and spotting"
HPI- 22-year-old female Caucasian female came in to the clinic with right sided abdominal
pain and spotting since this morning. She has missed her last period and she stated her
periods are irregular. She denies any fever, chills, or diarrhea. Associated symptoms
include nausea and vomiting. She stated her pain is sharp, crampy and intermittent pain in
the right lower abdomen. She rated the severity of pain as 6/10 and gets worse when she
moves, coughs or straining of bowels. She has not tried any medication or alternative
therapy
Gynecologic Health History: Menarche was at age of 10. Menstrual cycles irregular,
currently sexually active, single partner, last PAP done 6 months ago with normal results.
Not on any birth control methods. LMP- 12/11/18
OB History: G0P0
Allergies: NKDA
Current Medications: None
Immunization History: Up to date on all vaccines, Flu shot received on 1/6/19
PMH: None
Surgical History: None
Hospitalization: None
Family History: Both parents are healthy with no significant medical history, maternal
grandmother with DM, HLD. Maternal grandfather -smoker, COPD, DM. No family history
of cancer.
https://www.coursehero.com/file/40070242/Week-11-SOAP-note-ob-gyndocx/
, Week 11 SOAP note ob-gyn
This study source was downloaded by 100000832558064 from CourseHero.com on 05-24-2022 06:33:03 GMT -05:00
https://www.coursehero.com/file/40070242/Week-11-SOAP-note-ob-gyndocx/
Week 11 SOAP NOTE
Name: K.J Age: 22 Gender: Female Ethnicity: Caucasian
Subjective
Chief Complaint: "Abdominal pain and spotting"
HPI- 22-year-old female Caucasian female came in to the clinic with right sided abdominal
pain and spotting since this morning. She has missed her last period and she stated her
periods are irregular. She denies any fever, chills, or diarrhea. Associated symptoms
include nausea and vomiting. She stated her pain is sharp, crampy and intermittent pain in
the right lower abdomen. She rated the severity of pain as 6/10 and gets worse when she
moves, coughs or straining of bowels. She has not tried any medication or alternative
therapy
Gynecologic Health History: Menarche was at age of 10. Menstrual cycles irregular,
currently sexually active, single partner, last PAP done 6 months ago with normal results.
Not on any birth control methods. LMP- 12/11/18
OB History: G0P0
Allergies: NKDA
Current Medications: None
Immunization History: Up to date on all vaccines, Flu shot received on 1/6/19
PMH: None
Surgical History: None
Hospitalization: None
Family History: Both parents are healthy with no significant medical history, maternal
grandmother with DM, HLD. Maternal grandfather -smoker, COPD, DM. No family history
of cancer.
https://www.coursehero.com/file/40070242/Week-11-SOAP-note-ob-gyndocx/
, Week 11 SOAP note ob-gyn
This study source was downloaded by 100000832558064 from CourseHero.com on 05-24-2022 06:33:03 GMT -05:00
https://www.coursehero.com/file/40070242/Week-11-SOAP-note-ob-gyndocx/
