M94 W5 Soap Note
ID: S. L is a 24-year-old female
Cc: “Acute lower abdominal pain for the past 1 week”
Subjective:
She reports sharp, intermittent pain in the lower abdomen, worsening with movement.
Associated symptoms: nausea, mild fever, and bloating.
Denies vomiting or changes in bowel movements.
LMP: March 1, 2025. She denies irregular menstrual cycles.
No history of similar pain.
Abdominal exam: Tenderness in the lower abdomen, no rebound tenderness, normal bowel sounds
Pelvic exam: No abnormal discharge; mild cervical motion tenderness
Labs and so on…..