Medical Soap Note

Prepared by: [Your Name]

I. Subjective

A. Chief Complaint

The patient reports a 2-day history of mild to moderate abdominal pain, which is constant and worsens after eating.

B. History of Present Illness

A 32-year-old female with no significant past medical history. The pain is described as dull and localized to the lower right quadrant of the abdomen. The patient also reports mild nausea but denies vomiting, diarrhea, or fever.

C. Past Medical History

No chronic conditions. No history of abdominal surgery or gastrointestinal issues.

D. Medications

Occasional over-the-counter antacids.

E. Allergies

No known drug allergies.

F. Review of Systems

System	Findings
Gastrointestinal	Positive for nausea. No vomiting, diarrhea, or constipation.
Cardiovascular	No chest pain, palpitations, or edema.
Respiratory	No shortness of breath, cough, or wheezing.
Genitourinary	No urinary symptoms.

II. Objective

A. Vital Signs

Vital Sign	Measurement
Blood Pressure	120/80 mmHg
Heart Rate	76 bpm
Respiratory Rate	16 breaths/min
Temperature	98.6°F (37°C)
Oxygen Saturation	98% on room air

B. Physical Examination

System	Findings
General	Alert, well-nourished female in no acute distress.
Abdomen	Tenderness to palpation in the right lower quadrant.
	No rebound tenderness or guarding.
	Bowel sounds normal.
Other systems	Normal exam findings.

C. Diagnostic Tests

None were performed at this visit.

III. Assessment

A. Differential Diagnosis

Acute appendicitis
Gastroenteritis
Irritable bowel syndrome (IBS)

B. Primary Diagnosis

Acute abdominal pain, possible early appendicitis.

IV. Plan

A. Further Testing

Order abdominal ultrasound to assess for signs of appendicitis. Consider a CT scan if symptoms worsen or remain unresolved.

B. Treatment

Prescribe pain management with acetaminophen.
Recommend clear liquids diet until symptoms resolve.

C. Follow-up

Follow up in 2-3 days or sooner if symptoms worsen. Advise the patient to seek immediate medical attention if pain becomes severe or if fever develops.

D. Patient Education

Educate the patient on signs of appendicitis and the importance of early intervention if symptoms change.

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