CC: prenatal revisit- SOAP 2

CC: prenatal revisit-

S: RP, a 27-year-old G3P0A1L1 at 37 weeks gestation presenting for a routine prenatal visit. She reports symptoms consistent with an upper respiratory infection, including congestion, mild cough, and rhinorrhea. No fever, chills, dyspnea, or chest pain. No contractions, leakage of fluid, or vaginal bleeding. Good fetal movement was noted.

O:VS: BP: 128/88 mmHg (right arm, seated), Heart Rate: 62 bpm Respiratory Rate: 17 breaths per minute, Temperature: 98.6°F, Spo2: 100%, Room air G3 T0P0A1L1. Gestational Age: 37 weeks, Fundal Height: 37 cm, Fetal Movement: Positive, Fetal Heart Rate (FHR): 147 bpm, reassuring, GBS Status: Negative

A: 37 weeks gestation, routine prenatal visit. Upper respiratory infection, likely viral etiology, COVID-19 swab test was performed, No signs of labor or obstetric complications.

P: Supportive care for URI includes increasing hydration, getting plenty of rest, using steam inhalation, applying saline nasal spray, and taking acetaminophen as needed for fever or discomfort. Pregnant individuals should avoid decongestants.

Monitor symptoms carefully. Return to the clinic if the fever persists (above 100.4°F), if symptoms worsen, or if fetal movement is decreased.

Routine prenatal care requires a clinic visit in 1 week for fetal monitoring and ongoing prenatal evaluation.

Labor precautions involve counseling on signs of labor, such as contractions, rupture of membranes, or decreased fetal movement, and guidance on when to go to labor and delivery.