Abdominal Pain (RLQ)

SOAP Note

Subjective (S)

CC: Abdominal pain x 12 hours HPI: 24 y/o male with periumbilical pain migrating to RLQ. Sharp, constant, 8/10. Worse with movement/coughing. Associated nausea, 1x vomiting, subjective fever, anorexia.

Objective (O)

Vitals: BP 128/78, HR 98, RR 18, Temp 100.8°F Abdomen: Flat, hypoactive BS, RLQ tenderness, +rebound, +guarding. McBurney's positive. Rovsing's positive.

Assessment (A)

Primary Dx: Acute Appendicitis (suspected) Classic migration of pain, positive peritoneal signs, low-grade fever. Alvarado Score: 8

Plan (P)

1. NPO 2. IV fluids 3. Labs: CBC, CMP, UA, lipase 4. CT abdomen/pelvis Surgical consult notified