Comprehensive SOAP:
Patient Initials: T.R. Age: 32 years Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): “The skin on my abdomen has several dark but painless lines. I have been having them since my sixth weeks of pregnancy. A recent photo of my abdomen is as shown in picture no. 2 in the file.”
History of Present Illness (HPI): T.R. is a 32-year-old African American who has come to the hospital unaccompanied. In addition to obtaining her routine antenatal care, T.R. is concerned about several dark marks that are appearing on her abdomen. As reported by T.R., the marks started to develop when she was in her sixth weeks of pregnancy and they have become darker. She thought they will soon disappear but they have not. She has been pregnant for 35 weeks now. T.R. is not using any potent corticosteroids. She denies redness or itchiness of the darkened lines.
Medications:
Allergies:
Denies food or drug allergies
Past Medical History (PMH):
1.) Tonsilitis during adolescent years
3.) Malaria 4 months ago
Past Surgical History (PSH):
Denies having an operation before.
Sexual/Reproductive History:
T.R. is of the female gender. Her first menarche was at 13 years. She reports have regular menstrual cycle before her pregnancy. She is at gravida 1, para 0. T.R. denies experiencing any serious complications with her current pregnancy.
She had a pap smear test before she became pregnant and results were negative.
Personal/Social History:
T.R. indicates that she is married and faithful to her husband. She is an office secretary and her husband is an accountant. The couple denies consuming cigarettes or alcohol.
Immunization History:
Covid Vaccine: AstraZeneca- 1st dose 8/9/2020, 2nd dose 10/8/2021
Significant Family History:
Both parents are alive and healthy.
Lifestyle:
T.R.’s primary diet comprises of carbohydrates, fruits, and vegetables with little fat.
Review of Systems:
General: Reports a slight increase in weight due to pregnancy. Denies fever.
HEENT: Does report physical head injury or headache. Denies vision-related issues. Does not report hearing loss or ear pain. Denies nasal congestion or discharge. Does not report mouth ulcers. Denies hoarseness in the threat.
Breasts: Does not report pain, redness, lesions, or masses.
Respiratory: Denies wheezing or breathing difficulties.
Cardiovascular: Denies chest discomfort or dyspnea.
Gastrointestinal: Does not report abdominal pain or diarrhea.
Genitourinary: Reports increased urination frequency.
Musculoskeletal: Does not report joint pain or stiffness.
Skin/hair/nails: Indicates that there has been an increase in the number of dark stretch marks on her abdomen.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Temperature; 35.6 degree Celsius, Blood pressure; 132/80, Pulse; 92 beats per minute, weight; 157.6 pounds, respiratory rate; 20 breaths per minute.
General: Alert and oriented to time, place, and person.
HEENT: Head is negative for trauma. Eyes lack evidence of lesions or swelling. Ear canal is clear. Nasal mucosa is pink and hairy. Absence of mouth ulcers. Throat is non-erythematous.
Neck: No goitre.
Chest/Lungs: No rubs, wheezes, or crackles, rubs.
Heart/Peripheral Vascular: S1, S2. Normal heart rate. No murmurs or gallop.
ABD: Evidence of abdominal distention and several dark striae.
Musculoskeletal: Good balance. Normal gait.
Neuro: Sings of good consciousness. No evidence of memory, language or speech, problems.
Skin: Smooth and warm skin. Several hyperpigmented striae or streaks on the distended abdomen. Order this paper