SOAP Note 2 Week 5

1. Review the SOAP note resources provided in the course content.

2. 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.

3. Download the SOAP Form: Access the attached SOAP form. This form will serve as your template for documenting the patient encounter.

4. 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.

5. 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.

6. 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.

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.