Obstetrics appointment

  HERE IS THE SCENARIO TO WRITE THE SOAP ON A 33-year-old female, Charisse, presents for her 36-week obstetrics appointment. Charisse indicates that her hands are swollen every day, and that she had a headache for three days last week that rated a pain level of 7/10 that was in the temporal area bilaterally. Charisse reveals that one day last week, her vision seemed “off” but notes that her ophthalmologist warned her that some pregnant women will have some vision changes, so Charisse thought nothing of it. She reports good baby movement and occasional contractions that do intensify but resolve with five (5) minutes of rest; there was no pattern to the contractions, and they were inconsistent. Vital Signs • Wt. 215 lb. (an increase of 5 lb. since last week) • HR 88 • BP 178/92