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 CareY.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 HistoryA 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.

SOAP NOTE

Patient Name/Identifier: Y.C.
Age: 35
Gender: Female
Gestational Age: 28 weeks (G1P0)
Date of Visit: //2026
Provider: ___________________

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S – Subjective

Y.C., a 35-year-old woman who is 6 months pregnant, reports a 1-week history of intermittent right upper quadrant (RUQ) and mid-back pain. She describes the pain as sharp and episodic, occurring throughout the day and night, and often accompanied by nausea and occasional vomiting. She notes that taking a hot bath provides some relief; however, over-the-counter pain medications and repositioning have not been effective. Y.C. also mentions feeling “somewhat feverish at times,” though she has not measured her temperature. She denies constipation, urinary symptoms, vision changes, or current sinus complaints. Her current medication includes prenatal vitamins only. Y.C.’s past medical history includes polycystic ovary syndrome (PCOS) and chronic sinusitis with a history of deviated septum repair.

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O – Objective

General: Well-nourished woman appearing her stated age, in mild discomfort due to back and RUQ pain. Weight gain appropriate for gestational age.

Vital Signs:

• Heart rate: 78 bpm, regular

• Blood pressure: 128/62 mmHg

• Respiratory rate and temperature: not documented

Head, Eyes, Ears, Nose, Throat (HEENT): Denies visual problems; no current sinus issues; occasional nasal congestion noted with pregnancy.

Neck: No lymphadenopathy or thyroid enlargement; neck supple.

Cardiovascular (CV): S1/S2 normal, no murmurs; peripheral pulses equal and strong.

Respiratory: Lungs clear bilaterally with equal breath sounds; no wheezes or crackles.

Abdomen: Abdomen appears rounded consistent with pregnancy; no hepatomegaly; RUQ tenderness present with palpation; gallbladder is palpable and tender; no rebound tenderness.

Neurological: Oriented to person, place, time, and situation; gait steady; no changes in mood or memory reported.

Skin: Intact, smooth, dry; no rashes or lesions.

Genitourinary (GU): No dysuria, frequency, or urgency.

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A – Assessment

Primary Assessment:

1. Suspected biliary colic or cholelithiasis in pregnancy – Y.C.’s symptoms of episodic RUQ pain radiating to the back, nausea, and tenderness over the gallbladder are characteristic of gallbladder dysfunction during pregnancy. Gallstones are a common cause of RUQ pain in this population due to hormonal changes that slow bile flow (Ko et al., 2020, DOI: 10.1053/j.gastro.2019.10.018).

2. Rule out acute cholecystitis – Although fever is reported subjectively and not objectively confirmed, acute inflammation of the gallbladder remains a concern that requires further evaluation (Yokoe et al., 2018, DOI: 10.1007/s00534-017-1432-1).

Additional Considerations:

• Preeclampsia less likely given normal blood pressure and absence of edema or proteinuria.

• Pancreatitis is less likely but should be excluded if pain worsens or lab findings suggest it.

Clinical Reasoning:
The episodic nature of the pain, relief with non-pharmacologic measures, and absence of severe systemic symptoms suggest gallbladder stones or biliary colic as the leading diagnosis; however, the subjective sensation of fever warrants imaging and labs to confirm or rule out inflammation.

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P – Plan

Diagnostics:

1. Right upper quadrant ultrasound – First-line imaging in pregnancy to evaluate gallstones, biliary ductal dilation, and signs of cholecystitis.

2. Laboratory tests:

   • Complete blood count (CBC) to assess for leukocytosis

   • Liver function tests (AST, ALT, ALP, bilirubin)

   • Pancreatic enzymes (amylase, lipase) to exclude pancreatitis

   • Pregnancy-specific labs per routine obstetric care

Medications & Symptom Management:

• Pregnancy-safe analgesics as recommended by obstetrician (e.g., acetaminophen if not contraindicated).

• Consider pregnancy-appropriate antiemetics for nausea.

Patient Education:

• Advise on low-fat dietary modifications to reduce gallbladder stimulation.

• Educate on warning signs that require urgent care: increasing pain severity, high fever, jaundice, persistent vomiting, or decreased fetal movement.

Referrals and Follow-Up:

• Referral to general surgery for consultation if ultrasound confirms gallstones or if symptoms worsen or become constant.

• Continue routine obstetrics follow-up, with instructions to report any new or severe symptoms immediately.

• Schedule follow-up appointment within 48–72 hours or sooner if symptoms escalate.

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References (Past 5 Years)

1. Ko, C. W., et al. (2020). Management of gallstone disease during pregnancy. Gastroenterology Clinics of North America. DOI: 10.1053/j.gastro.2019.10.018

2. Yokoe, M., et al. (2018). Updated guidelines for the management of acute cholecystitis (Tokyo Guidelines 2018). Journal of Hepato-Biliary-Pancreatic Sciences. DOI: 10.1007/s00534-017-1432-1

 

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