SOAP Note for Abdominal Pain

Subjective

Obtain a focused history targeting these discriminating features:

Pain characteristics: Onset (sudden vs. gradual), location (generalized vs. localized), migration pattern (pain migrating to right lower quadrant suggests appendicitis), quality, severity, and duration 1, 2
Timing and triggers: Relationship to meals (postprandial pain suggests biliary disease, mesenteric ischemia, or functional dyspepsia), specific food triggers (high-fat meals, dairy, wheat/gluten, high FODMAP foods) 1
Associated symptoms: Fever, vomiting (vomiting before pain onset makes appendicitis less likely), diarrhea, constipation, weight loss, nocturnal symptoms, rectal bleeding 1, 2
Red flag features requiring urgent investigation:
- Age >50 years with new-onset symptoms 1
- Unintentional weight loss 1
- Nocturnal diarrhea or rectal bleeding 1
- Family history of GI malignancy or inflammatory bowel disease 1
Past medical/surgical history: Prior abdominal surgeries (raises concern for adhesive small bowel obstruction), atherosclerotic risk factors (consider mesenteric ischemia if age >60), atrial fibrillation, recent cholecystectomy 1, 2

Vital signs and hemodynamic assessment:

Check for signs of instability first: Fever, tachycardia, tachypnea, hypotension, altered mental status indicate potential organ failure requiring immediate resuscitation 2
Establish IV access and initiate fluid resuscitation if signs of sepsis or shock are present 2

Physical examination - key discriminating findings:

Peritoneal signs: Rebound tenderness, guarding, rigidity (indicate surgical emergency) 2
Psoas sign: Positive finding with right lower quadrant pain strongly suggests appendicitis 2
Abdominal distension: Combined with constipation strongly suggests bowel obstruction 3
Elderly patients may have normal labs despite serious infection, so maintain high clinical suspicion 2

Laboratory testing:

First-line labs: Complete blood count, comprehensive metabolic panel, inflammatory markers (CRP), celiac serology 1
Lactate: Order if concerned for bowel ischemia or sepsis 2
Fecal calprotectin: If diarrhea is present to exclude inflammatory bowel disease 1
Note: Elevated CRP is a significant predictive factor for hospital admission (OR = 6.24) 4

Imaging strategy:

For generalized abdominal pain: CT abdomen/pelvis with IV contrast is the primary imaging modality after ensuring hemodynamic stability, as it changes diagnosis in 51-54% of cases and alters management in 25-42% of patients 2
For right upper quadrant pain: Ultrasonography is the initial imaging test of choice 5
For right or left lower quadrant pain: CT is recommended 5
Do NOT delay CT for oral contrast - it delays diagnosis without improving accuracy 2
Single-phase IV contrast-enhanced CT is sufficient; pre-contrast and delayed phases are unnecessary 2
Plain radiographs have limited diagnostic value and should generally be avoided except when bowel obstruction is strongly suspected clinically 2
Do not obtain repeat CT scans without clear clinical indication - diagnostic yield drops from 22% on initial CT to 5.9% on fourth or subsequent CTs 2

Differential diagnosis framework:

In ED patients with generalized abdominal pain: one-third have no diagnosis established, one-third have appendicitis, and one-third have other documented pathology including small bowel obstruction, pancreatitis, renal colic, perforated peptic ulcer, and malignancy 2
Distinguish organic disease from functional disorders - functional disorders should be considered only after organic pathology has been confidently excluded 6

Pain control:

Provide early analgesia without compromising diagnostic accuracy 2
Avoid opioids in chronic or functional abdominal pain - they cause narcotic bowel syndrome, dependence, gut dysmotility, and increased mortality 2

VTE prophylaxis:

Administer low-molecular-weight heparin for VTE prophylaxis in all patients with acute abdominal pain, as this population carries high thrombotic risk 2

Antibiotic administration:

Do NOT routinely administer antibiotics for undifferentiated abdominal pain 2
Antibiotics are indicated only when: intra-abdominal abscess is identified, clinical signs of sepsis are present, or specific infection is confirmed 2
For confirmed intra-abdominal infections: Metronidazole is indicated for peritonitis, intra-abdominal abscess, and infections caused by susceptible anaerobic bacteria including Bacteroides species and Clostridium species 7

For meal-related or functional abdominal pain:

First-line dietary interventions: Small frequent meals, avoid high-fat foods, limit caffeine and alcohol, adequate hydration 1
Second-line dietary therapy: Soluble fiber supplementation (ispaghula), low FODMAP diet supervised by trained dietitian 1
First-line pharmacologic management: Antispasmodics (dicyclomine, hyoscyamine, or peppermint oil) 1
Second-line pharmacologic management: Tricyclic antidepressants (amitriptyline) or SNRIs (duloxetine) for refractory or severe pain 1
Psychological interventions: Cognitive behavioral therapy and gut-directed hypnotherapy are effective for severe symptoms and refractory pain; initiate early alongside medical therapy 1

Surgical consultation is needed for:

Refer to gastroenterology if:

Alarm features are present 1
Diagnostic uncertainty exists after initial workup 1
Failure to respond to first-line therapies within 8-12 weeks 1
Age >50 with new symptoms, alarm features, or family history of GI malignancy (consider endoscopy) 1
Centrally mediated pain refractory to neuromodulators (consider multidisciplinary pain management) 1

Common pitfall: Once a diagnosis of functional pain is established, repetitive testing is not recommended 6