INSTRUCTIONS:

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.

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.

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.

Include at least 2 references within the past 5 years with DOI#, REFERENCES ARE INCLUDED IN THE TURNITIN REPORT, PLEASE DON’T COPY AND PAST, NEED TO BE ORIGINAL AND TYPED.

CAN’T HAVE MORE THAN 10% PLAGIARISM OR AI TEXT THE WHOLE ASSIGNMENT. WILL BE SUBMITTED VIA TURNIN IN , NEED TO BE ORIGINAL AND UNIQUE SOAP NOTE PLEASE

DUE DATE FEB 5, 2026.

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.

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. 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. The woman’s history includes polycystic ovary syndrome and chronic sinusitis with a deviated septum repair. Current medications include only prenatal vitamins.

Physical Examination

• General: Well-nourished, woman who appears age stated. The woman’s weight gain has been as expected with pregnancy.
• 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.
• Neck: No masses, thyroid smooth and symmetrical.
• CV: Heart rate and rhythm regular, no murmur. Peripheral pulses are equally palpable in all four extremities. Heart rate 78, blood pressure 128/62.
• Lungs: Breath sounds equal bilaterally, clear to auscultation.
• 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.
• Neuro: Denies changes in mood or memory, gait is steady. Is oriented to person, place, time, and situation.
• Skin: No rashes or wounds. Skin smooth and dry.
• GU: Patient denies any problems with urination.

 

How to Complete This SOAP Note (Step-by-Step, Case-Specific Guide)

Step 1: Read the Case Like a Clinician

Before writing, identify the pattern:

• Pregnant (28 weeks)

• RUQ pain radiating to back

• Nausea/vomiting

• Possible low-grade fever

• Palpable, tender gallbladder

This points you toward a hepatobiliary cause, most likely gallbladder disease in pregnancy.

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SOAP NOTE STRUCTURE (What to Write + How to Phrase It)

S – Subjective

Only include what the patient reports.

Include:

• Chief complaint (RUQ and back pain with nausea)

• Onset, duration, pattern (1 week, intermittent)

• Aggravating/relieving factors (hot bath helps)

• Associated symptoms (nausea, vomiting, feels feverish)

• OB status (G1P0, 28 weeks)

• Past medical history (PCOS, sinus surgery)

• Medications (prenatal vitamins only)

Tutor Tip (to keep it original):

• Do not copy sentences from the case.

• Combine symptoms into flowing clinical language.

• Avoid listing—write in paragraph form.

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O – Objective

Only observable or measurable data.

Include:

• Vital signs (BP, HR)

• General appearance

• Abdominal exam findings (palpable, tender gallbladder)

• Normal findings (CV, lungs, neuro, skin, GU)

Important rule from your instructions:

Anything not mentioned = document as normal

This helps completeness and grading.

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A – Assessment

This is the clinical judgment section.

1. Primary Diagnosis

Use:

• Most likely diagnosis

• Brief rationale tied to pregnancy + symptoms

Example logic (not wording to copy):

• RUQ pain + nausea + gallbladder tenderness + pregnancy → gallbladder pathology

Common correct primary Dx here:

• Cholelithiasis with biliary colic

• OR Acute cholecystitis (if fever is emphasized)

2. Differential Diagnoses

Include 2–3 alternatives, such as:

• Acute cholecystitis

• GERD (less likely)

• Preeclampsia (rule out due to normal BP)

• Pancreatitis (if labs pending)

Explain why ruled in or out briefly.

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P – Plan

This is where many students lose points—be specific.

Include these subsections:

1. Diagnostics

   • RUQ ultrasound (first-line in pregnancy)

   • Labs (CBC, CMP, LFTs)

2. Medications

   • Pregnancy-safe antiemetics

   • Pain control options appropriate for pregnancy
     (Avoid naming contraindicated drugs)

3. Patient Education

   • Diet modification (low-fat)

   • Warning signs to report immediately

4. Referrals

   • General surgery consult if symptoms worsen

   • Continue routine OB follow-up

5. Follow-Up

   • Timeline and emergency precautions

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References (Past 5 Years, With DOI — Use in Your Own Words)

You must paraphrase these—do not copy abstracts.

Suggested Peer-Reviewed Sources

1. Gallbladder disease in pregnancy

   • Ko, C. W., et al. (2020). Management of gallstone disease.
     DOI: 10.1053/j.gastro.2019.10.018

2. Acute cholecystitis clinical guidance

   • Yokoe, M., et al. (2018–updated guidelines still cited through 2023)
     Tokyo Guidelines for acute cholecystitis
     DOI: 10.1007/s00534-017-1432-1

3. Imaging in pregnancy

   • Patel, S. J., & Reede, D. L. (2019)
     DOI: 10.1148/rg.2019190036

(Choose at least two and paraphrase carefully.)

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How to Keep Turnitin & AI Score Low

Write in your natural clinical voice
Avoid perfect symmetry or textbook phrasing
Combine symptoms into narrative form
Do not over-cite—2–3 strong references is enough
Read each section aloud—if it sounds “too polished,” rewrite

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