clinical Case Study: Evaluation of Lower Abdominal
Pain and Vaginal Spotting in a 30-Year-Old Female
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Patient information
Item Details
Age 30 years
Sex Female
Height 5’7” (170 cm)
Weight 136 lb (61.8 kg)
Setting Emergency Department
, Reason for Lower abdominal pain with
Encounter vaginal spotting
Source of Patient
History
Reliability Good
Chief Complaint (CC)
Category Statement
CC “I’m having lower abdominal pain and some
spotting.”
History of Present Illness (HPI)
# Category Question (Provider) Patient Response
1 HPI How can I help you I’ve been having pain in
today? my lower abdomen and
some spotting.
2 HPI When did this start? Earlier today, maybe 5–6
hours ago.
3 HPI Was the onset It started gradually and got
sudden or gradual? worse.
4 HPI Where is the pain Low in my abdomen,
located? mostly in the center.
5 HPI Does the pain move No, it stays right there.
anywhere else?
6 HPI How would you Crampy and sometimes
describe the pain? sharp.
Pain and Vaginal Spotting in a 30-Year-Old Female
week 9 Full Case& Soap Note | Instant Pdf After
Purchase
Patient information
Item Details
Age 30 years
Sex Female
Height 5’7” (170 cm)
Weight 136 lb (61.8 kg)
Setting Emergency Department
, Reason for Lower abdominal pain with
Encounter vaginal spotting
Source of Patient
History
Reliability Good
Chief Complaint (CC)
Category Statement
CC “I’m having lower abdominal pain and some
spotting.”
History of Present Illness (HPI)
# Category Question (Provider) Patient Response
1 HPI How can I help you I’ve been having pain in
today? my lower abdomen and
some spotting.
2 HPI When did this start? Earlier today, maybe 5–6
hours ago.
3 HPI Was the onset It started gradually and got
sudden or gradual? worse.
4 HPI Where is the pain Low in my abdomen,
located? mostly in the center.
5 HPI Does the pain move No, it stays right there.
anywhere else?
6 HPI How would you Crampy and sometimes
describe the pain? sharp.
