Comprehensive SOAP: Integumentary
Patient Initials: AB Age: 27 years Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): “I have dark stretch marks on my abdomen.”
History of Present Illness (HPI): Alice Brenda is a 27-year-old Hispanic female who has visited the clinic for her usual antenatal care. AB is in her 36th week of pregnancy. She denies having any health issues today. However, she is concerned about the increasing number of dark stretch marks on her abdomen as shown in picture number 2. The marks started to appear during her fifth week of pregnancy but they were not as many as they are today.
USE COUPON GURU15 AND GET 15% DISCOUNT ON ALL ORDERS
Besides, they have become darker than they were four months ago. AB reports that this is her first pregnancy and that she has never seen such marks on any parts of her body before. She denies using systemic steroids or potent corticosteroids. The marks do not occur with any other symptoms/discomfort such as itching or redness. She is not using any medications at the moment to manage the stretch marks. AB is on folic acid and iron supplements which she has been taking since she began her antenatal care.
Medications:
Allergies:
Amoxicillin – rash
Denies food allergies
Past Medical History (PMH):
1.) Pneumonia
2.) Tonsilitis
3.) Cellulitis
Past Surgical History (PSH):
Denies
Sexual/Reproductive History:
AB identifies as a female. Menarche was at age 13. She used to have a regular menstrual cycle taking 28-30 days. Her menses normally last 4 days when she is not pregnant and they occur with minimal cramping. AB denies using any method of contraption before her pregnancy. She had a pap smear test before she became pregnant and results were negative.
Personal/Social History:
AB has been married to her husband for 2 years. They live together in the city. AB works as a nurse at community hospital. She does not smoke cigarettes and denies consuming alcohol. She drinks 2 cups of coffee every morning. She denies illicit drug use.
Immunization History:
Influenza Vaccination 09/2/2021
Tdap 2/8/2019
PNV 18/9/2020
Covid Vaccine #1 7/8/2021 #2 8/10/2021 AstraZeneca
Significant Family History:
AB’s father is 54 years old. He was recently diagnosed with type 2 diabetes mellitus which is well controlled. Her mother is 49 years old and she is healthy. She has 2 sisters (17 and 14 years) who are both healthy. Her paternal and maternal grandparents are all deceased.
Lifestyle:
AB eats vegetables and fruits together with her daily meals. Her typical diet is mainly Hispanic diet. She drinks four glasses of water per day and reports walking to work every day. She denies going to the gym.
Review of Systems:
General: No chills or night sweats; reports recent weight gains as the fetus continues to grow; reports occasional fatigue; Denies nausea, vomiting, or fever
HEENT: Denies physical head injury. Denies a headache. Does not report redness and pain in the issues. No vision issues reported. Does not report a history of cataracts. Denies using contact glasses. Does not report double vision or excessive tearing. Denies ear pain, hearing loss, ear infection, or hearing in the ears. No nasal stuffiness reported. Does not report nasal discharge or obstruction. No recent changes in smell reported. Denies a history of nasal infections. No mouth ulcers, pain, or dryness reported. Denies hoarseness of the throat. Denies a history of mouth or throat infections.
Neck: Denies swelling, pain, injury, compression, or history of disc disease.
Breasts: Denies redness, rashes, masses, or a history of lesions. Reports soreness or mild pain in the breasts since the first trimester of pregnancy.
Respiratory: Denies difficulty breathing. Reports occasional coughs. No hemoptysis reported. Denies pleuritic chest pain, wheezing, or cyanosis. Reports a history of pneumonia. Denies a history of tuberculosis.
CV:
Quality Work
Unlimited Revisions
Affordable Pricing
24/7 Support
Fast Delivery