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Prenatal Visit Soap Note

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Prenatal Visit Soap Note-G2P1000 at 19 weeks, 6 days with EDD of 8/7/09 confirmed by U/S. Without complaints today. Denies n/v, abdominal pain, contractions, vaginal bleeding, dysuria, or lower extrem ... ity swelling. Excited that she felt quickening 6 days ago. Had anatomy U/S at 18 weeks – normal anatomy and a boy. FOB is excited for pregnancy –not present today. Pt. has questions today re: exercise in pregnancy. Currently works out at the YMCA 4‐5 times a week x 45 min. – walks/runs on treadmill and does weight training. Denies HA, dizziness, SOB, chest pain, cramping, or discomfort while doing these activities. States that she feels “great” when exercising and is without complaint, but her husband is concerned and wants to be sure it is okay for her to continue her current exercise regimen. Also has questions re: sexual activity during pregnancy – she and her husband are currently having intercourse 2‐3 times/week, which is “more often than with the first pregnancy.” Reports no pain or discomfort with intercourse. Wants to know if there is anything about their sexual activities that should be altered for pregnancy, i.e. frequency. Sexual hx: Monogamous with husband of 5 years, 4 lifetime partners, all male. No STI hx. Feels sex life is “good” at present. See HPI for questions re: current sexual activity. PMH/SH: No history of abnormal paps, no medical conditions. OB hx: SVD at 41wks, boy, 8#40z on 2/10/2007, mild PP hemorrhage, no sequela. Psychosocial: Denies smoking, recreational drug use. Approximately 2 glasses wine/week prior to pregnancy. 4‐year college degree, currently stay‐at‐home mom with 2 year old son. Describes stress as 3/10. Exercises Lives with husband and son, denies emotional or physical abuse. No pets. No caffeine intake. Pt. parents live nearby. Medications: Prenatal multivitamin, OTC. Immunizations: Up to date. Tetanus shot 2 years ago. Chicken pox in childhood. [Show More]

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