MSN 572 Week 3 Assignment 1 SOAP Note: Patient with Acute Right Upper Quadrant Pain

Patient with Acute Right Upper Quadrant Pain

ID: R.L., 45-year-old female, DOB: 04/15/1978, White, accompanied by self, historian is patient.

Chief Complaint (CC)

“I have a sharp pain in my upper right stomach that started after dinner last night.”

History of Present Illness (HPI)

45-year-old female presenting with a 12-hour history of acute right upper quadrant (RUQ) abdominal pain.

Onset: Pain began approximately 1 hour after eating a greasy, fried chicken dinner last evening. It started suddenly.
Location: Primarily in the right upper quadrant, with radiation through to the right scapula.
Duration: Constant since onset, lasting for approximately 12 hours.
Character: Described as a sharp, “colicky” or cramping pain, rated as 7/10 in severity at its peak.
Aggravating Factors: Exacerbated by deep inspiration and movement. The patient reports a similar, but milder, episode a few weeks ago after eating pizza.
Relieving Factors: Partially relieved by sitting still and leaning forward. Over-the-counter antacids provided no relief.
Timing: This is the second episode in a month, both following high-fat meals.
Severity: Associated with multiple episodes of nausea and two non-bloody, non-bilious vomiting episodes. The patient denies fever, chills, or changes in urine/stool color.

Focused Past Medical History

PMH: Hypertension, well-controlled with Lisinopril 10mg daily.
PSH: Tonsillectomy (age 6).
Medications: Lisinopril 10mg daily. No over-the-counter supplements. No known drug allergies.
SH: Denies tobacco use. Reports drinking 1-2 glasses of wine socially on weekends. Works as a teacher. Lives with husband.
FH: Mother with hypertension and hyperlipidemia. Father with type 2 diabetes. No known family history of gallbladder disease.

Focused Review of Systems (ROS)

Constitutional: Denies fever, chills, or unintended weight loss. Reports fatigue from poor sleep due to pain.
Gastrointestinal: As per HPI: Positive for RUQ pain, nausea, and vomiting. Denies diarrhea, constipation, melena, or hematochezia. Denies jaundice.
Cardiovascular: Denies chest pain or palpitations.
All other systems are reviewed and are negative.

Focused Physical Exam

Vital Signs: BP 138/84 mmHg, HR 92 bpm, RR 18 bpm, Temp 98.7°F (oral), SpO2 99% on room air.
General: Patient is alert, oriented x4. Appears uncomfortable, sitting forward on the exam table and guarding her abdomen.
Abdominal:
- Inspection: Non-distended, no visible scars, masses, or discoloration.
- Auscultation: Bowel sounds are normoactive in all four quadrants.
- Percussion: Tympanitic throughout. Positive for Murphy’s Sign (the patient arrested inspiration abruptly due to pain upon deep palpation in the RUQ).
- Palpation: Tenderness to deep palpation in the RUQ. No rebound tenderness or guarding. No palpable masses.

Assessment

Diagnostic Final Conclusion: Biliary Colic (K80.20)

The primary and working diagnosis of this patient is biliary colic. Clinical manifestation of the condition is typical, with acute and colicky pain of the right upper quadrant (RUQ), which extends to the right scapula. The pain, which is postprandial following consumption of a high-fat meal, is a characteristic symptom since dietary fats activate gallbladder contractile response against a stone that blocks the cystic duct. These signs are absent, including systemic indicators of infection, e.g., fever or leukocytosis, and physical examination, e.g., no peritoneal signs (rebound tenderness), etc. helps to differentiate simple biliary colic and a more developed complication, i.e., acute cholecystitis. A positive Murphy sign is also another localization of pathology, indicating that the gallbladder is affected (Doherty et al., 2022). The combination of a typical history and a narrow physical examination finding is what makes biliary colic the most likely diagnosis.

Differential Diagnosis 1: Functional Dyspepsia (K30).

Functional dyspepsia is a differential diagnosis because the patient reports having epigastric pain and nausea after meals. This is a disorder characterized by persistent or repeated pain in the upper belly with no clear structural or biochemical etiology. It is adjudicated on the first instance since it may have its symptoms intersect with several upper GI disorders. Nevertheless, it cannot be considered the first factor of causality in this situation since the pain experienced by the patient is not an indistinct discomfort or uncomfortable fullness after eating (Rosca et al., 2025). Rather, it is a localized and acute, colicky pain, more localized to the RUQ and has clear radiation to the back, not typical of functional dyspepsia. The acute and episodic character directly connected to the consumption of high-fat foods is rather suggestive of a structural problem, such as the presence of gallstones, than a functional disorder.

Differentiation Diagnosis 2: Gastroesophageal Reflux Disease (GERD) (K21.9).

GERD can also be considered as a part of the differential since the patient has upper abdominal pain and nausea, which may appear during uncharacteristic manifestations of reflux. It is taken into consideration due to the frequent occurrence of dietary triggers in GERD. But GERD is eliminated because of the nature of the pain and its location. The patient reports a sharp, colicky pain in the RUQ with scapular radiation that is not consistent with the usual retrosternal, burning heartburn that is typical of GERD (Hossa & Małecka-Wojciesko, 2025). In addition, the pain was not found to be associated with recumbency, which was another factor that is likely to aggravate reflux. The examinations, such as RUQ tenderness and the positive Murphy sign, were specific to the present case, not related to GERD, and thus, this diagnosis is excluded.

Plan

Diagnostic Plan

The primary diagnostic workup will be aimed at the establishment of the suspected biliary pathology and elimination of alternative causes. The initial test that is the gold standard is a Right Upper Quadrant Abdominal ultrasound because it is highly sensitive and specific regarding the detection and identification of gallstones and cholecystitis. Basic laboratory tests, such as a Complete Blood Count (CBC) to exclude the possibility of leukocytosis, a Comprehensive Metabolic Panel (CMP) to determine liver enzymes, bilirubin, and pancreatic enzymes, and Lipase level to exclude the possibility of pancreatitis, are also suggested to set a baseline and evaluate complications (Fujita et al., 2023).

Therapeutic Plan

The short-range therapeutic objective is symptom and pain management. An NSAID like Ibuprofen 600mg orally every 8 hours on demand due to pain will be prescribed because NSAIDs have been established to be useful in the management of biliary colic pain, as well as in the decrease of inflammation. In case of breakthrough nausea, Ondansetron 4mg tablet by mouth disintegrating every 8 hours as required will be prescribed as well (Fujita et al., 2023). The patient will be recommended to adhere to a clear liquid diet within the following 24 hours, where the gallbladder can rest, and then proceed to a low-fat diet, which should be taken in moderation.

Education Plan

The patient will be thoroughly educated regarding Biliary Colic and the pathophysiology in both regards of the presence of gallstones and ductal obstruction. The importance of a permanent low-fat diet in the prevention of further attacks will be underlined. The patient will also receive educational handouts on a low-fat diet and be advised to maintain a food diary to help them/use the alternative potential triggers. The reasons behind the diagnostic tests and why a surgical consultation may be required to achieve an elective cholecystectomy will be well demonstrated due to the frequency of her symptoms (Fujita et al., 2023). In relation to high-fat meals, the patient will be advised to avoid them unequivocally.

Referral Plan

An ultrasound confirmatory test will be regarded as an essential step towards initiating a referral to a General Surgeon to discuss the advantages and disadvantages of elective laparoscopic cholecystectomy, which is the absolute cure to symptomatic cholelithiasis.

Follow-up Plan

The patient will be advised to visit the clinic after one week with the outcome of her ultrasound and laboratory examinations to discuss the final management program. She shall be given explicit precautionary measures in case of sick days, where she is then advised to report to the closest emergency department to specify signs of acute cholecystitis or any other complications, including fever that is unremitting even with analgesics, intractable vomiting, increasing or severe pain in the abdomen, or jaundice (Fujita et al., 2023).

References

Doherty, G., Manktelow, M., Skelly, B., Gillespie, P., Bjourson, A. J., & Watterson, S. (2022). The need for standardizing diagnosis, treatment and clinical care of cholecystitis and biliary colic in gallbladder disease. Medicina, 58(3), 388. https://doi.org/10.3390/medicina58030388

Fujita, N., Yasuda, I., Endo, I., Isayama, H., Iwashita, T., Ueki, T., Uemura, K., Umezawa, A., Katanuma, A., Katayose, Y., Suzuki, Y., Shoda, J., Tsuyuguchi, T., Wakai, T., Inui, K., Unno, M., Takeyama, Y., Itoi, T., Koike, K., & Mochida, S. (2023). Evidence-based clinical practice guidelines for cholelithiasis 2021. Journal of Gastroenterology, 58(9), 801–833. https://doi.org/10.1007/s00535-023-02014-6

Hossa, K., & Małecka-Wojciesko, E. (2025). Advances in gastroesophageal reflux disease management: Exploring the role of potassium-competitive acid blockers and novel therapies. Pharmaceuticals, 18(5), 699. https://doi.org/10.3390/ph18050699

Rosca, V., Gheorghe, L., Floria, D., Vulpoi, R., Emanuela, G., Eliza, C., & Barboi, O. (2025). Functional dyspepsia assessment – Current diagnostic methods and new promising techniques. Archive of Clinical Cases, 12(1), 37–43. https://doi.org/10.22551/2025.46.1201.10310