SOAP Note Documentation for a Pregnant Patient with Right Upper Quadrant and Back Pain/ij6y

Posted: February 4th, 2025

Assignment Content
Question

Instructions for Completing the SOAP Note

Review the SOAP note resources provided in the course content.
It is essential to familiarize yourself with the structure and purpose of SOAP notes before beginning.

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.
Understanding the context of the patient’s condition will help you accurately complete the SOAP form.

Download the SOAP Form: Access the attached SOAP form. This form will serve as your template for documenting the patient encounter.
Ensure you have the correct version of the form to avoid formatting issues.

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.
Double-check your entries for accuracy and completeness before submission.

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.
Thorough documentation ensures effective communication among healthcare providers.

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.
Make sure to cite your reference in the appropriate format to avoid plagiarism.

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 patient’s symptoms may indicate a condition requiring further investigation.
The woman indicates she feels somewhat feverish at times but has not taken her temperature.
Feverish sensations could suggest an underlying infection or inflammatory process.

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.
Her discomfort may be related to her pregnancy or an unrelated condition.
This pain started approximately 1 week prior and comes and goes throughout the day and night. The patient reports a hot bath is the only relieving measure.
The intermittent nature of the pain suggests it may not be constant but still concerning.
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.
The lack of response to common remedies indicates the need for further evaluation.
The woman’s history includes polycystic ovary syndrome and chronic sinusitis with a deviated septum repair. Current medications include only prenatal vitamins.
Her medical history may provide clues to her current symptoms.

Physical Examination
General: Well-nourished, woman who appears age stated. The woman’s weight gain has been as expected with pregnancy.
Her general appearance suggests no immediate signs of distress.
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.
Nasal symptoms may be related to hormonal changes during pregnancy.
Neck: No masses, thyroid smooth and symmetrical.
A normal neck examination rules out thyroid-related issues.
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 examination is within normal limits.
Lungs: Breath sounds equal bilaterally, clear to auscultation.
No signs of respiratory distress or abnormalities.
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.
Gallbladder tenderness may indicate biliary colic or cholecystitis.
Neuro: Denies changes in mood or memory, gait is steady. Is oriented to person, place, time, and situation.
Neurological examination reveals no abnormalities.
Skin: No rashes or wounds. Skin smooth and dry.
Skin examination is unremarkable.
GU: Patient denies any problems with urination.
No urinary symptoms are reported.

“SOAP Note Documentation for a Pregnant Patient with Right Upper Quadrant and Back Pain: A Case Study Analysis”

SOAP note, pregnancy, right upper quadrant pain, case study, medical documentation

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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