D.W is a 29-year-old G2P1 female presents to the clinic with complaints of sharp, intermittent lower abdominal pain on the right side that started three days ago. She reports that the pain has gradually worsened and is now constant, radiating to her lower back. She also notes light vaginal spotting,

Ectopic Pregnancy Soap Note

You are going to create a soap note about this patient here: D.W is a 29-year-old G2P1 female presents to the clinic with complaints of sharp, intermittent lower abdominal pain on the right side that started three days ago. She reports that the pain has gradually worsened and is now constant, radiating to her lower back. She also notes light vaginal spotting, which she initially thought was an irregular period, but it has continued for several days. The patient states that she has been feeling lightheaded and nauseous since this morning. Her last menstrual period (LMP) was six weeks ago, and she has a history of irregular cycles. She had a positive home pregnancy test one week ago but has not yet had her first prenatal visit. She denies passing clots, fever, chills, dysuria, or recent infections.

Her past obstetric history includes one prior full-term vaginal delivery without complications. She has no known history of sexually transmitted infections (STIs), pelvic inflammatory disease (PID), or previous ectopic pregnancy. However, she does report a prior laparoscopic appendectomy at age 22. The patient is sexually active in a monogamous relationship and has not been using contraception

Ectopic Pregnancy Soap Note

On physical examination, she appears slightly pale and uncomfortable but is alert and oriented. Her vital signs show mild tachycardia (HR: 102 bpm), normal blood pressure (110/70 mmHg), and normal temperature (98.6°F). A pelvic examination reveals mild cervical motion tenderness, significant right adnexal tenderness, and a slightly enlarged uterus. No significant vaginal bleeding is observed. I am attaching the template so you can develop one. In addition to that I am attaching my previous one so you can understand about the references and in text citations and per reviewed rationales. Instructions:

Ectopic Pregnancy Soap Note

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instructions:

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S =Subjective data: Patient’s Chief Complaint (CC). O =Objective data: Including client behavior physical assessment vital signs and meds. A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis =Plan: Treatment diagnostic testing and follow up. SOAP starts Begins with patient initials, age, race, ethnicity and gender (5 demographics)

Chief Complaint (Reason for seeking health care)

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