Abdominal pain
Complete SOAP example
Example narrative
46-year-old woman from HOME, independent, reports 10 hours of worsening right-lower-quadrant pain with nausea and reduced appetite. Denies GI bleeding or urinary symptoms. Pregnancy possibility discussed privately.
Primary survey intact. Patient found side-lying in bed, alert and guarding lower abdomen. Serial vitals stable by measured values. Abdomen soft with focal tenderness; no pulsatile mass or overt bleeding identified.
Differential considerations: 1) appendiceal or other intra-abdominal inflammation, 2) gynecologic pathology, 3) renal or ureteric pathology. Focal abdominal pain without current shock.
Comfort positioning, monitoring and analgesia/antiemetic care provided per applicable guideline. Pain and abdominal findings reassessed. Transported to ED; history, pregnancy considerations, medications and response transferred.