Provide a sample SOAP note for a 45-year-old male presenting with two‑day left lower quadrant abdominal pain, diagnosed with uncomplicated acute sigmoid diverticulitis, including subjective, objective, assessment, and plan details.

Sample SOAP Note: Uncomplicated Acute Sigmoid Diverticulitis

SUBJECTIVE

Chief Complaint: "I've had left lower belly pain for 2 days."

History of Present Illness:
45-year-old male presents with 2 days of left lower quadrant (LLQ) abdominal pain. Pain is constant, sharp, rated 6/10 in severity, localized to LLQ without radiation. No vomiting. Reports decreased appetite but tolerating clear liquids. Denies fever, chills, or rigors at home. Reports mild constipation but no change in stool caliber, no blood in stool, no weight loss. No prior episodes of similar pain. No recent antibiotic use.

Past Medical History: Hypertension (controlled)
Medications: Lisinopril 10 mg daily
Allergies: NKDA
Social History: Non-smoker, occasional alcohol use
Family History: Non-contributory

OBJECTIVE

Vital Signs:

• Temperature: 37.8°C (100°F)
• BP: 138/82 mmHg
• HR: 88 bpm
• RR: 16/min
• SpO2: 98% on room air

Physical Examination:

• General: Well-appearing, in no acute distress, ambulatory
• Abdomen: Soft, direct tenderness isolated to LLQ, no rebound or guarding, no peritoneal signs, normal bowel sounds, no palpable masses
• No costovertebral angle tenderness

Laboratory Results:

• WBC: 12.5 × 10⁹/L (normal differential)
• CRP: 85 mg/L
• Creatinine: 0.9 mg/dL (normal)

Imaging:
CT abdomen/pelvis with IV contrast: Sigmoid colon wall thickening with pericolonic fat stranding. No abscess, perforation, fistula, or obstruction. No pericolic extraluminal air. Inflamed segment <5 cm. Modified Hinchey Classification: Stage 0 (uncomplicated diverticulitis).

ASSESSMENT

Acute uncomplicated sigmoid diverticulitis in an immunocompetent, well-appearing patient with appropriate social support and ability to follow up.

Rationale:

• Clinical presentation (LLQ pain, tenderness, no vomiting) with CRP >50 mg/L supports diagnosis 1
• CT confirms uncomplicated disease (no abscess, perforation, or obstruction) 2
• Patient meets criteria for outpatient management: immunocompetent, no sepsis, no severe comorbidities, tolerating oral intake, reliable for follow-up 2, 3
• CRP <140 mg/L, WBC <15 × 10⁹/L, no vomiting, symptoms <5 days—low risk for progression to complicated disease 3

PLAN

1. Disposition: Outpatient Management
Discharge home with close outpatient follow-up 2, 4. Patient is well-appearing, hemodynamically stable, tolerating oral intake, has adequate home support, and meets all criteria for ambulatory treatment.

2. Antibiotic Therapy: Selective Use
Initiate oral antibiotics given mild elevation in inflammatory markers (CRP 85 mg/L, WBC 12.5) 3. While antibiotics can be used selectively in immunocompetent patients with mild uncomplicated diverticulitis 2, 3, this patient's presentation warrants treatment given:

• Elevated inflammatory markers (though below high-risk thresholds)
• First episode (no established pattern of uncomplicated disease)
• Patient preference for active treatment

Antibiotic regimen:

• Ciprofloxacin 500 mg PO BID + Metronidazole 500 mg PO TID for 7 days 5
• Alternative: Amoxicillin-clavulanate 875 mg PO TID if no penicillin allergy 5

3. Dietary Management

• Clear liquid diet for 2-3 days during acute phase 3
• Advance diet as tolerated based on symptom improvement
• Patient may advance more quickly if comfortable doing so 3

4. Pain Control

• Acetaminophen 1000 mg PO TID as needed 5
• Avoid NSAIDs

5. Follow-up and Red Flags
Return immediately or call if:

• Fever >38.5°C (101.3°F)
• Persistent vomiting or inability to tolerate oral intake
• Worsening abdominal pain
• Development of peritoneal signs
• Inability to advance diet after 3-5 days 3

Scheduled follow-up:

• Phone check-in at 48-72 hours
• Office visit in 1 week if symptoms not improving

6. Colonoscopy

• Schedule colonoscopy in 6-8 weeks to exclude colorectal malignancy and confirm diagnosis 3
• No alarm symptoms present (no change in stool caliber, no iron deficiency anemia, no blood in stool, no weight loss)

7. Patient Education

• Explained diagnosis, natural history, and treatment plan
• Discussed that most patients respond well to outpatient management 4
• Reviewed red flag symptoms requiring immediate return
• Discussed recurrence risk and importance of colonoscopy follow-up

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Clinical Pearls for This Case:

• Outpatient management is safe and effective for select patients with uncomplicated diverticulitis 2, 4
• Predictors of complicated disease include: symptoms >5 days, vomiting, CRP >140 mg/L, pericolic air, or longer inflamed segments 2
• This patient has none of these high-risk features
• Antibiotic use should be selective but reasonable in this context given inflammatory markers and first presentation 3