i-HUMAN CASE STUDY WEEK#9 (30-YRS-OLD
FEMALE WITH LOWER ABDOMINAL PAIN &
SPOTTING)
i-HUMAN CASE STUDY – WEEK #9
,30-Year-Old Female With Lower Abdominal Pain & Vaginal Spotting
Full Patient Introduction & Demographics
• Name: Jessica Miller (simulated)
• Age: 30 years
• Sex: Female
• Ethnicity: Not specified
• Source of History: Patient (reliable historian)
• Chief Complaint (CC):
“I’ve been having lower abdominal pain with some vaginal spotting.”
History of Present Illness (HPI)
Jessica Miller is a 30-year-old female who presents to the outpatient clinic with lower abdominal pain
and abnormal vaginal spotting for the past 3 days. The pain is described as a dull, crampy discomfort,
localized to the suprapubic and bilateral lower abdominal regions, rated 6/10 in severity. The pain has
been intermittent, with no clear relieving factors, and is worsened by movement.
She reports light vaginal spotting, dark red to brown in color, not associated with her normal menstrual
cycle. Her last menstrual period (LMP) was 6 weeks ago, and she reports irregular menses over the
past few months. She admits to unprotected sexual intercourse with one male partner and is not
currently using contraception.
Associated symptoms include mild nausea and breast tenderness, but she denies vomiting, fever, chills,
dysuria, urinary frequency, flank pain, foul-smelling vaginal discharge, or recent trauma. She denies
passing clots or tissue.
She has no prior history of ectopic pregnancy but reports one prior spontaneous vaginal delivery 5
years ago. No history of pelvic inflammatory disease (PID) or sexually transmitted infections (STIs).
Given the combination of lower abdominal pain, spotting, and delayed menses, pregnancy-related
complications are a significant concern.
Past Medical History (PMH)
• No chronic medical conditions reported
• No history of hypertension, diabetes, or thyroid disease
, Past Surgical History (PSH)
• None
Obstetric & Gynecologic History
• Gravida 1, Para 1
• Last Pap smear: 1 year ago (normal)
• No history of abnormal Pap smears
• No known STIs
• Menstrual cycles: Previously regular, recently irregular
Medications
• Occasional ibuprofen for pain
• No hormonal contraceptives
Allergies
• No known drug allergies (NKDA)
Family History
• Mother: Hypertension
• Father: Type 2 diabetes
• No family history of gynecologic cancers or clotting disorders
Social History
• Sexually active with one male partner
• No tobacco use
• Occasional alcohol use
• Denies illicit drug use
Review of Systems (ROS)
FEMALE WITH LOWER ABDOMINAL PAIN &
SPOTTING)
i-HUMAN CASE STUDY – WEEK #9
,30-Year-Old Female With Lower Abdominal Pain & Vaginal Spotting
Full Patient Introduction & Demographics
• Name: Jessica Miller (simulated)
• Age: 30 years
• Sex: Female
• Ethnicity: Not specified
• Source of History: Patient (reliable historian)
• Chief Complaint (CC):
“I’ve been having lower abdominal pain with some vaginal spotting.”
History of Present Illness (HPI)
Jessica Miller is a 30-year-old female who presents to the outpatient clinic with lower abdominal pain
and abnormal vaginal spotting for the past 3 days. The pain is described as a dull, crampy discomfort,
localized to the suprapubic and bilateral lower abdominal regions, rated 6/10 in severity. The pain has
been intermittent, with no clear relieving factors, and is worsened by movement.
She reports light vaginal spotting, dark red to brown in color, not associated with her normal menstrual
cycle. Her last menstrual period (LMP) was 6 weeks ago, and she reports irregular menses over the
past few months. She admits to unprotected sexual intercourse with one male partner and is not
currently using contraception.
Associated symptoms include mild nausea and breast tenderness, but she denies vomiting, fever, chills,
dysuria, urinary frequency, flank pain, foul-smelling vaginal discharge, or recent trauma. She denies
passing clots or tissue.
She has no prior history of ectopic pregnancy but reports one prior spontaneous vaginal delivery 5
years ago. No history of pelvic inflammatory disease (PID) or sexually transmitted infections (STIs).
Given the combination of lower abdominal pain, spotting, and delayed menses, pregnancy-related
complications are a significant concern.
Past Medical History (PMH)
• No chronic medical conditions reported
• No history of hypertension, diabetes, or thyroid disease
, Past Surgical History (PSH)
• None
Obstetric & Gynecologic History
• Gravida 1, Para 1
• Last Pap smear: 1 year ago (normal)
• No history of abnormal Pap smears
• No known STIs
• Menstrual cycles: Previously regular, recently irregular
Medications
• Occasional ibuprofen for pain
• No hormonal contraceptives
Allergies
• No known drug allergies (NKDA)
Family History
• Mother: Hypertension
• Father: Type 2 diabetes
• No family history of gynecologic cancers or clotting disorders
Social History
• Sexually active with one male partner
• No tobacco use
• Occasional alcohol use
• Denies illicit drug use
Review of Systems (ROS)
