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Question: Hannah is 38 years old, 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 7 days.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Subjective: What other relevant questions should you ask regarding the HPI? O- when did you started to experience the headaches? A couple weeks agoL- What side of your head is the pain located? In the front of my head both sidesD- How long does the headache lasts? For a couple hoursC- How does the headache feels? Throbbing, aching, pressure or pulsating? PulsatingA- What makes the headache better or worse? When I lay down in my bed the headaches tend to get worst. Tylenol usually helpsR- Does the headache radiates to your neck or any other part of your head? No, it does not radiate T- At what time during the day do you experience the headaches? Usually in the afternoonS- Scale 0-10 what number will you give the headache? 7• Have you hurt your head recently? No• Are you drinking enough water?• Any changes in your vision? No• Any changes in your mental status? No• Any recent seizure activity? No• Have you change anything in your diet? I have been craving a lot of food containing carbohydrates
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