soap note

Case #1. Teresa.

History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office

today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to

progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on

day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to

discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.

She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the

lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She

is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa

tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband

thinks I am a bad mother”.

Prior medical history: None. Prior surgical history: Appendectomy (2000)

Current medications: Prenatal vitamins, stool softener. Allergies: None

OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.

Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of

sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a

normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.

LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:

Oral contraceptives, condoms.

Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or

recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.

Family history: Unremarkable.

Review of Systems (ROS): Negative except as noted in HPI.

Physical Exam (PE)

VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.

Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or

lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,

you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is

otherwise unremarkable.

Case #2. Joanna.

History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with her

father and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does not

have health insurance. Joanna presents to your office at the community health center today stating she

is pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for this

pregnancy as she was afraid to take time off from work and did not have enough money to pay for the

visit.

Prior medical history: None. Prior surgical history: None

Current medications: None. Allergies: Penicillin

OB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregular

cycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexually

transmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations of

pregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications during

her prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratory

distress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).

LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.

Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH or

recreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and her

mother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.

Family history: Mother (deceased age 55)- Type 2 diabetes.

Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past

1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for the

past month.

Physical Exam (PE)

VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbs

On physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone

(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discoloration

of the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motion

tenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at the

umbilicus. Joanna’s physical exam is otherwise unremarkable.

Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.

Case #3. Monica.

History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currently

separated from her husband of 20 years and is working full-time as a legal secretary. About 8 months

ago, Monica started having irregular periods with heavier than usual flow until she stopped having

periods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”

however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.

She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. She

comes to the clinic today to discuss menopause symptoms and hormone replacement therapy.

Prior medical history: Hypertension (2010)- well controlled on current antihypertensive

Prior surgical history: Cholecystectomy (2015)

Current medications: Lisinopril 10mg daily. Allergies: None

OB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimester

miscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 pads

per day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2

years ago).

LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.

Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.

Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.

Review of Systems (ROS): Unremarkable with exception of as noted in HPI.

Physical Exam (PE)

VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.

Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. You

check a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that a

urine pregnancy test came back positive.

Monica is in disbelief.

Case #4. Laura.

History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office after

missing her second period. She is “worried” as she “always gets her period on time”. She is in high

school- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urine

pregnancy test in clinic today is positive.

Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.

She reports being treated at the health department for chlamydia and gonorrhea earlier this year. She

thinks her boyfriend was treated but he is not answering her calls since she told him about the missed

periods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.

Prior medical history: None. Prior surgical history: None

Current medications: None. Allergies: None

OB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.

History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time of

chlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.

LMP: Approximately 2 months ago. Contraception history: Withdrawal

Social history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currently

smoking 1 pack of cigarettes/ day

Family history: Mother deceased at age 42- drug overdose. Father unknown.

Review of Systems (ROS): Unremarkable with exception of as noted in HPI.

Physical Exam (PE)

VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).

Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculum

exam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-week

size uterus on bimanual.

Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.

Case #1. Teresa.

History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002. She presents to your office

today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to

progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on

day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to

discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital.

She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the

lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She

is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa

tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband

thinks I am a bad mother”.

Prior medical history: None. Prior surgical history: Appendectomy (2000)

Current medications: Prenatal vitamins, stool softener. Allergies: None

OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.

Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of

sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a

normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.

LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history:

Oral contraceptives, condoms.

Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or

recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.

Family history: Unremarkable.

Review of Systems (ROS): Negative except as noted in HPI.

Physical Exam (PE)

VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.

Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or

lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam,

you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is

otherwise unremarkable.

Case #2. Joanna.

History of Present Illness (HPI): Joanna is a 28-year-old Caucasian G4P1021. She is single, living with her

father and 2-year-old daughter. She has a part-time job as a server at the local restaurant; she does not

have health insurance. Joanna presents to your office at the community health center today stating she

is pregnant and wants to receive OB care. She tells you that she has not yet been evaluated for this

pregnancy as she was afraid to take time off from work and did not have enough money to pay for the

visit.

Prior medical history: None. Prior surgical history: None

Current medications: None. Allergies: Penicillin

OB- GYN History: NSVD (2021) healthy female 6lb 8oz. Menarche age 10, cycle length- 3 days- irregular

cycles since menarche- frequency every 20-30 days- 2-3 tampons per day. No history of sexually

transmitted infections (STDs). Joanna’s OB history includes two first trimester elective terminations of

pregnancy, and 1 term female infant delivered vaginally at 37 weeks. Denies any complications during

her prior pregnancy however, she notes that her daughter experienced hypoglycemia and respiratory

distress, spending 2 weeks in the Neonatal Intensive Care Unit (NICU).

LMP: Approximately 5 months ago. Contraception history: Condoms “sometimes”.

Social history: Lives with her retired father and daughter. Restaurant server. Denies EtOH or

recreational drug use. Currently smoking 1 pack of cigarettes/ day (15 pack-year history). She and her

mother are still paying for her daughter’s NICU stay. The child’s father is not involved in any way.

Family history: Mother (deceased age 55)- Type 2 diabetes.

Review of Systems (ROS): Unremarkable with exception of dysuria (“it burns when I pee”) over the past

1-week. Denies fever, chills, abdominal or flank pain. Thick white vaginal discharge and “itching” for the

past month.

Physical Exam (PE)

VS: BP: 108/68, P: 72, RR: 18, T: 37.3, Weight 144lbs

On physical exam you palpate a fundal height of approximately 20cm with an audible fetal heart tone

(FHT) of 160. On speculum exam you visualize a multiparous cervix without lesions; bluish discoloration

of the cervix, vagina, and vulva is noted with a thick, white discharge. There is no cervical motion

tenderness (CMT) on exam. The uterus is anteverted, non- tender, with fundus palpable at the

umbilicus. Joanna’s physical exam is otherwise unremarkable.

Wet mount reveals budding yeast. Urine dipstick with 1+ leukocytes, trace blood and 2+ glucose.

Case #3. Monica.

History of Present Illness (HPI): Monica is a 43-year-old African- American G3P2102. She is currently

separated from her husband of 20 years and is working full-time as a legal secretary. About 8 months

ago, Monica started having irregular periods with heavier than usual flow until she stopped having

periods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”

however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.

She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. She

comes to the clinic today to discuss menopause symptoms and hormone replacement therapy.

Prior medical history: Hypertension (2010)- well controlled on current antihypertensive

Prior surgical history: Cholecystectomy (2015)

Current medications: Lisinopril 10mg daily. Allergies: None

OB- GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimester

miscarriage (9 weeks) in 2014. Menarche age 15, cycle length-7 days- frequency every 28 days- 5-6 pads

per day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2

years ago).

LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.

Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.

Family history: Mother deceased (age 60)- breast cancer. Father alive (age 70)- hypertension.

Review of Systems (ROS): Unremarkable with exception of as noted in HPI.

Physical Exam (PE)

VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.

Physical exam is unremarkable with exception of a palpable 12- 14 weeks size uterus on bimanual. You

check a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that a

urine pregnancy test came back positive.

Monica is in disbelief.

Case #4. Laura.

History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office after

missing her second period. She is “worried” as she “always gets her period on time”. She is in high

school- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urine

pregnancy test in clinic today is positive.

Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control.

She reports being treated at the health department for chlamydia and gonorrhea earlier this year. She

thinks her boyfriend was treated but he is not answering her calls since she told him about the missed

periods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.

Prior medical history: None. Prior surgical history: None

Current medications: None. Allergies: None

OB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.

History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time of

chlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.

LMP: Approximately 2 months ago. Contraception history: Withdrawal

Social history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currently

smoking 1 pack of cigarettes/ day

Family history: Mother deceased at age 42- drug overdose. Father unknown.

Review of Systems (ROS): Unremarkable with exception of as noted in HPI.

Physical Exam (PE)

VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).

Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculum

exam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-week

size uterus on bimanual.

Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.