Discuss the following: Soap Note A 25-year-old woman (G1P0) at approximately 10 weeks’ gestation presented for her first prenatal appointment. She reported nausea and vomiting for the past week.

Assignment Question

Discuss the following: Soap Note A 25-year-old woman (G1P0) at approximately 10 weeks’ gestation presented for her first prenatal appointment. She reported nausea and vomiting for the past week. She is not able to tolerate liquids and bland solid foods due to constant nausea and vomiting. She had no significant medical or surgical history and no known drug allergies. She also reported weight loss of 2lbs since onset of her symptoms. In office she has normal VS, however has positive ketones on Urinalysis. Vital signs: temperature, 98.7°F; heart rate, 86 beats/min; blood pressure, 110/80 mm Hg; 99% RA Upon Physical Examination – Unremarkable physical exam other than dry mucus membranes. SOAP format Subjective (S) – Chief complaint – History of Present illness – ROS – Past medical Hx – Past Surgical Hx – Social Hx – Family Hx – Recent Travel Objective (O) – Vital signs – Labs / Imaging – Head to toe assessment – Any other pertinent objective data Assessment – Primary diagnosis listed first – Any secondary diagnoses – Include at least three differentials Plan (P) – Treatment Plan – address each diagnosis provided – Implementation – Teaching – Address referral and follow up – Health Promotion and Disease Prevention Include at least in 2 references/ treatment guidelines in your diagnose APA