Emergency Medicine Detailed SOAP

Subjective:
Chief Complaint:
Abdominal pain in the right upper quadrant

History of Present Illness:

This very pleasant patient with a history of trisomy 21 presents with a two-night history of right upper quadrant abdominal pain. According to the patient's mother, the patient typically goes to bed around 9 or 10 PM but has recently been waking up during the night, screaming and touching his right upper abdomen. The pain is primarily localized to the right upper quadrant but has occasionally involved both sides of the abdomen. There are no reports of associated symptoms such as fever, vomiting, or changes in bowel or urinary habits. No prior history of gallbladder removal is reported.

Review of systems: The patient denies respiratory distress. No mention of gastrointestinal bleeding, jaundice, or other systemic symptoms.

Past Medical History:

- Trisomy 21 (Down syndrome)
- No prior history of cholecystectomy

Current Medications:

Allergies:

Social History:

- Patient does not use a CPAP mask at night

Objective:
Physical Examination:
Physical Examination:
The patient appears well and is in no distress.
Vitals as above are noted

Cardiovascular:  Normal S1, S2.  No S3 or S4.  No murmurs.  Extremities warm and pink.  No peripheral edema. 
Respiratory:  Good air entry bilaterally.  Equal.  No adventitious sounds. 
Abdomen: Tenderness to palpation in the right upper quadrant. No rebound or percussion tenderness. Abdomen otherwise soft. No costovertebral angle tenderness to percussion.
Neuro: Moves all four extremities, face symmetrical
Dermatologic: Rash noted on the face in a pattern consistent with CPAP mask irritation

Test Results:
Vital signs: Blood pressure 121/75 mmHg, pulse 66 beats per minute, temperature 36.7°C, oxygen saturation 99% on room air, respiratory rate normal. Complete blood count shows no signs of infection. Electrolytes and kidney function are normal. Blood glucose is 5.9 mmol/L. Pancreatic enzymes are normal. Urinalysis is clear. Liver enzymes and bilirubin are pending. Abdominal ultrasound is ordered to evaluate the gallbladder.

Assessment:
Summary Statement:
Assessment/plan: Right upper quadrant abdominal pain, possible biliary etiology

The patient with a history of trisomy 21 presents with two nights of right upper quadrant abdominal pain, with nocturnal episodes of severe discomfort and localized tenderness on examination. Laboratory evaluation reveals no evidence of infection, normal pancreatic enzymes, normal electrolytes, and clear urine. Physical examination is notable for right upper quadrant tenderness and a facial rash in a CPAP mask distribution, though the patient does not use a CPAP mask at night. The patient is kept nil per os, intravenous fluids are initiated, pain management is provided via intramuscular injection, and abdominal ultrasound and liver function tests are ordered to further evaluate for biliary pathology.

Discharge instructions will be provided following completion of diagnostic evaluation and reassessment.