Posted: February 4th, 2025

SOAP Note Documentation: Case Study on RUQ Pain in Pregnancy

Patient Initials: Pt. Encounter Number:
Date: Age: Sex:
Allergies: Advanced Directives:

SUBJECTIVE
CC:

HPI: Describe the course of the patient’s illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:

Current Medications:

PMH

Medication Intolerances:

Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx:

Hospitalizations/Surgeries:

Family History:

Social History:

ROS
General
Cardiovascular

Skin
Respiratory

Eyes
Gastrointestinal

Ears
Genitourinary/Gynecological

Nose/Mouth/Throat
Musculoskeletal

Breast
Neurological

Heme/Lymph/Endo
Psychiatric

OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
PHYSICAL EXAMINATION
General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

Lab Tests

Special Tests
Diagnosis
• Primary Diagnosis-
 Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.

o Differential Diagnoses- Include three diagnoses

PLAN including education
o Plan:
 Further testing
 Medication
 Education
 Non-medication treatments
 Referrals
 Follow-up visits

References

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Assignment Content
Question

Instructions for Completing the SOAP Note

Review the SOAP note resources provided in the course content. These materials will help you understand the proper structure and expectations for documentation. Make sure to familiarize yourself with best practices for clinical note-taking.

Read the Case Study: Begin by carefully reading the case study provided below. Pay close attention to the patient’s background, medical history, and presenting complaint. Identifying key symptoms and medical history will ensure an accurate and thorough assessment.

Download the SOAP Form: Access the attached SOAP form. This form will serve as your template for documenting the patient encounter. It is essential to use the correct format to ensure clarity and consistency in your documentation.

Complete the SOAP Form: Using the information from the case study, fill out the SOAP form to the best of your ability. Ensure that you provide details for each section: Subjective, Objective, Assessment, and Plan. Any part of the assessment not mentioned in the case study is considered normal. Providing thorough documentation ensures a more precise diagnosis and treatment plan.

Thoroughness is Key: Aim to complete each section of the SOAP form as comprehensively as possible. Include relevant information obtained from both the patient’s subjective account and objective observations. A well-documented SOAP note aids in continuity of care and improves patient outcomes.

Submit Your Completed SOAP Note: Once you have filled out the SOAP form, submit your completed document according to the instructions provided by your instructor. Include at least 1 reference. Ensure that the reference is from a credible source, such as a peer-reviewed journal or clinical guideline.

CASE STUDY: Pain in Right Upper Quadrant and Back
Reason for Seeking Care

Y.C. is a 35-year-old woman who is 6 months pregnant and presents to her obstetrics appointment with complaints of periodic pain in the right upper quadrant and mid-back. This pain tends to accompany nausea and sometimes episodes of vomiting. The woman indicates she feels somewhat feverish at times but has not taken her temperature. Her symptoms raise concerns for potential gallbladder involvement, given the location of her pain and associated nausea.

History of Present Illness and Health History

A 35-year-old pregnant woman, G1P0, presents for her routine obstetric examination at 28 weeks. The woman appears her stated age and appears to be somewhat uncomfortable due to reported back pain and right upper quadrant pain. This pain started approximately 1 week prior and comes and goes throughout the day and night. Given the intermittent nature of the pain, it is crucial to assess possible triggers and exacerbating factors.

The patient reports a hot bath is the only relieving measure. The pain does not respond to repositioning, OTC pain medication, or other measures. The woman reports nausea with the pain and occasional vomiting also associated with the pain. Since she is currently pregnant, careful consideration must be given to diagnostic procedures and treatment options.

The woman’s history includes polycystic ovary syndrome and chronic sinusitis with a deviated septum repair. Current medications include only prenatal vitamins. A thorough review of her medical history is essential to rule out any underlying conditions that could contribute to her symptoms.

Physical Examination

General: Well-nourished woman who appears age stated. The woman’s weight gain has been as expected with pregnancy. Her overall nutritional status and prenatal care adherence are important factors in assessing her current health status.

Head: Denies vision problems and does not wear glasses or contact lenses. History of sinus problems but no current concerns. Occasional nasal stuffiness was reported with pregnancy. Sinus congestion can sometimes worsen during pregnancy due to hormonal changes, but no acute issues are noted at this time.

Neck: No masses, thyroid smooth and symmetrical. Given the absence of palpable abnormalities, thyroid dysfunction is unlikely to be contributing to her symptoms.

CV: Heart rate and rhythm regular, no murmur. Peripheral pulses are equally palpable in all four extremities. Heart rate 78, blood pressure 128/62. Her cardiovascular assessment is within normal limits, suggesting no immediate concerns related to hypertension or circulatory complications.

Lungs: Breath sounds equal bilaterally, clear to auscultation. No signs of respiratory distress, wheezing, or crackles, which helps rule out pulmonary involvement in her symptoms.

Abdomen: No hepatomegaly, abdomen slightly rounded related to pregnancy, denies constipation. Currently has sharp pain in RUQ and radiating to back. The gallbladder is palpable, and the patient reports tenderness. The presence of RUQ pain and gallbladder tenderness raises suspicion for possible cholecystitis or gallstones, which warrant further investigation.

Neuro: Denies changes in mood or memory, gait is steady. Is oriented to person, place, time, and situation. Cognitive function is intact, with no neurological deficits noted during the assessment.

Skin: No rashes or wounds. Skin smooth and dry. The absence of skin abnormalities suggests no dermatological manifestations of systemic illness.

GU: Patient denies any problems with urination. No reported dysuria, frequency, or hematuria, ruling out immediate genitourinary concerns.

SOAP Note Documentation: Case Study on RUQ Pain in Pregnancy,
SOAP note, pregnancy assessment, right upper quadrant pain, clinical documentation, gallbladder evaluation

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Tags: A Case Study Analysis, Case Study, medical documentation, pregnancy, right upper quadrant pain