The Setting
SOAP Report
Subjective/Story/Summary
The patient is a 17-year-old male who is complaining of severe abdominal pain. The patient’s tentmates woke us at 6:30AM and said the patient had severe belly pain. Patient states the pain began yesterday at 10:00AM as “a bad bellyache cramping-like,” but is now “sharp.” He thought it was indigestion. It persisted all night and became “really uncomfortable” at about 10:00PM last night. The pain is across the lower abdominal quadrants, does not radiate, and is presently an 8 on a 1-10 scale.
Objective
Patient is obviously uncomfortable from the pain. Patient states the pain is worse when he walks, especially when he walks downhill or hops.
Patient Exam: There is no point tenderness or rebound pain. No signs of injury or rigidity to the belly.
Vital Signs
| TIME | 6:45AM | 7:15AM | 8:00AM |
| LOC | AOX4 | AOX4 | AOX4 |
| HR | 84, strong, regular | 84, strong, regular | 84, strong, regular |
| RR | 16, regular, easy | 16, regular, easy | 16, regular, easy |
| SCTM | Pale, Warm, Dry | Pale, Warm, Dry | Pale, Warm, Dry |
| BP | not taken | not taken | not taken |
| Pupils | PERRL | PERRL | PERRL |
| Temp | 99°F oral | 99°F oral | 99°F oral |
History
| Symptoms: | Patient is nauseous. No other complaints. |
| Allergies: | Patient denies any allergies. |
| Medications: | Patient denies any medications. |
| Pertinent medical history: | Patient denies any history of abdominal problems. |
| Last intake/output: | Patient has been well-hydrated and denies diarrhea. He ate very little for dinner last night. Reports normal bowel movement yesterday; no bowel movement yet today. Patient urinated clear urine this morning. He drank one cup of water this morning. |
| Events relevant to the incident/illness: | Patient’s tentmates are not ill. They say the patient moaned from the pain all night long, but did not want to wake up the leaders. The patient denies a blow to the abdomen. |
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