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SOAP Note
Mariam Garcia
Purdue University Global
MN569
June 7, 2022
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Chief Complain (CC): Abdominal Pain
History of Present Illness (HPI): Patient is a 31-year-old male who presents with a complaint
of right lower abdominal pain x4 days. The onset of the pain has been gradual and has been
occurring in an intermittent pattern for 4 hours. Pain is described as being located in the right
lower quadrant. The pain does not radiate. The symptoms have no aggravating factors. The
symptoms are relieved by bending forward. Has not taken any medication for the pain. The
patient was seen at UCC 4 days ago and sent to the ER for evaluation of possible appendicitis.
The patient then left ER without being seen. The pain got worse 2 days ago but has since
improved, currently, the pain is just mild pressure. Does not know what caused the pain. Works
as a construction worker but does not think it was a musculoskeletal injury. Reports urinary
frequency and urgency, feeling of incomplete bladder emptying. No burning, fever, chills, n/v/d,
constipation, or flank pain.
Allergies: No Known Drug Allergies
Past Medical History: No Known Problems
Family History:
Hypertension: Father
Myocardial Infarction: Father
Diabetes Mellitus Type II: Father
Surgery History: No Past Surgical History
Social History (alcohol, drug, or tobacco use):
Preferred Language: Spanish
Tobacco use: Never smoker
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Drug use: None
Alcohol use: Occasional (social drinking, 2 beers)
Current medications:

Omeprazole (20MG Tablet DR, 1 (one) oral daily
Review of Systems:
General Not Present- Chills and Fever.
Skin Not Present- Rash.
HEENT Not Present- Dizziness and Headache.
Respiratory Not Present- Cough, Shortness of Breath and Wheezing.
Cardiovascular Not Present- Chest Pain and Shortness of Breath.
Gastrointestinal Present- Abdominal Pain (Right lower quadrant). Not Present- Bloating,
Constipation, Diarrhea, Excessive gas, Indigestion, Nausea, Pain with Bowel Movement and
Vomiting.
Male Genitourinary Present- Frequency and Urgency. Not Present- Incontinence and Painful
Urination.
Vital Signs/ Height/Weight:
Temperature: 98.3 ºF. Pulse: 59, Respirations: 20, Blood Pressure: 122/90
Height: 169.1 cm, Weight: 148 lb., BMI: 23.57 kg/m²
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Physical Exam:
General - alert, well nourished, well groomed, no acute distress.
Chest and Lung Exam - normal breath sounds, no adventitious sounds on auscultation and
quiet, even, and easy respiratory effort with no use of accessory muscles.
Cardiovascular - normal heart sounds and regular rate and rhythm; no murmurs, rubs, or
gallops.
Abdomen - soft. Note: able to elicit minimal pain with RLQ palpation. No pain otherwise today.
Auscultation - bowel sounds normal.
Peripheral Vascular - no lower extremity edema bilaterally.
Assessment
A: Differential Diagnosis (Snyder, Guthrie & Cagle Jr, 2018):
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Kidney stones
2.
UTI
3.
STD
4.
MSK pain
5.
Constipation
6.
Appendicitis
1.
UA with small blood
2.
pain
UA negative for leukocytes or nitrates. Patient denies dysuria, fevers, or flank
3.
Patient denies multiple sex partners/new partners (currently married)
4.
Patient denies known injury. No injury at work or otherwise
B:
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5.
Patient reports recent bowel movement, states he has a bowel movement daily for
the most part
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No red flags for appendicitis on exam
PLAN
A: No red flags on exam today. Will check abdominal ultrasound and send urine sample for
culture and STD testing (Snyder, Guthrie & Cagle Jr, 2018).
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WSH URINALYSIS - IN HOUSE
2.
ULTRASOUND - ABDOMEN, COMPLETE
3.
Lab tests:
A.
URINE CULTURE
B.
NEISSERIA GONORRHOEAE
C.
CHLAMYDIA TRACHOMATIS
D.
TRICHOMONAS PCR
B: Follow-Up Plans: Patient to follow up after imaging, sooner for new or worsening symptoms.
ER precautions for fever, unable to tolerate PO, nausea, vomiting, or blood in stool (Taplitz,
Kennedy, Bow & Flowers, 2018).
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Cultural Diversity
The patient is Hispanic/Latino and spoke only Spanish. There are several barriers to care
since the patient was advised to go to the ER, yet decided to leave without being seen. These
barriers include language, lack of insurance, different cultural beliefs, and in some cases, illegal
immigration status, mistrust, and illiteracy (Ly, 2019). Cultural consideration for this patient
should include support of cultural beliefs and facilitation of communication (Cervantes,
Gattamorta & Berger-Cardoso, 2019). Therefore, as the health care provider, we should use an
interpreter service to reduce any stress or anxiety related to his care. Care is seen as time and
attention therefore care should not be rushed and conversation is important (Cervantes,
Gattamorta & Berger-Cardoso, 2019).
Patient/Family Education
The patient was currently on Omeprazole for heartburn. The patient was asked to
continue medication since it is helping with his heartburn symptoms. The patient did report that
the current pain in his abdomen was different than that of his previous epigastric pain related to
heartburn and indigestion. The patient was not prescribed any new medications since his right
lower quadrant pain was not intense and he declined pain medication.
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References
Cervantes, R. C., Gattamorta, K. A., & Berger-Cardoso, J. (2019). Examining difference in
immigration stress, acculturation stress and addressing cultural diversity in Hispanic
patients. Journal of Immigrant and Minority Health, 21(1), 14-20.
Ly, D. P. (2019). Racial and ethnic disparities in the evaluation and management of pain in the
outpatient setting. Pain Medicine Journal, 20(2), 223-232.
Snyder, M. J., Guthrie, M., & Cagle Jr, S. D. (2018). Acute abdominal pain: efficient diagnosis
and management. American family physician, 98(1), 25-33.
Taplitz, R. A., Kennedy, E. B., Bow, E. J., & Flowers, C. R. (2018). Outpatient management of
acute abdominal pain in adults. American Society of Infectious Diseases Journal, 36(14),
1443-1453.