Routine prenatal appointment

Assignment Help Science

Reference no: EM134017302

Question

Hannah is 38, G1P0, 32 weeks EGA, and comes to you for her routine prenatal appointment. Her BP is 156/96, and her urine has 2+ protein. She complains of having a headache that will not go away and just not feeling "right." for the past seven days.

In a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

1. Subjective:

a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other OB history questions should you ask?

2. Objective:

a. Describe the appropriate physical assessment that needs to be included in this visit.
b. Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.

3. Assessment/ Diagnosis:

a. What is your diagnosis?
b. Include any appropriate differential diagnosis

4. Plan:

a. Can this be managed via outpatient? Why? How will you manage this?
b. Do you feel that should be managed inpatient? Why? What do you think will be done to the patient?
c. If you choose to manage outpatient- explain the medication regimen, testing, and follow-up needed.
d. If you choose to manage inpatient- explain what medication and testing will be done in the patient and how you will continue management once the patient is discharged. What medication and testing do you need to continue for this patient?
e. What patient education is essential to include for this patient?
f. Explain complications that can occur if the patient does not comply with the treatment regimen.

Reference no: EM134017302

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