TRISTAN TAYLOR PRESENTING WITH
ACUTE RIGHT LOWER QUADRANT
ABDOMINAL PAIN, NAUSEA, AND LOW
GRADE FEVER AT EMERGENCY DEP
ARTMENT UTILIZING SYSTEMATIC HISTORY
DRIVEN ASSESSMENT, DIFFERENTIAL
DIAGNOSIS, AND EVIDENCE BA
, SOAP NOTE: TRISTAN TAYLOR
Patient Name: Tristan Taylor
Age: 28 years old
Gender: Male (assumed based on name)
Encounter Date: [Current Date]
Setting: Emergency Department
Chief Complaint: "I have this sharp pain in my lower right side, and I
feel like I'm going to throw up."
SUBJECTIVE (S)
History of Present Illness (HPI):
Tristan Taylor is a 28-year-old male who presents to the Emergency
Department with a chief complaint of acute onset right lower quadrant
(RLQ) abdominal pain that began approximately 12 hours ago. He
reports that the pain initially started around his belly button
(periumbilical region) and was dull and crampy in nature. Over the
past 6 hours, the pain has migrated to the right lower quadrant and