30 years Old Female With Lower Abdominal
Pain and Vaginal Spotting Full Case and
Soap Note
2026 Update Real Assignment
Patient Profile
• Name: Not disclosed
• Age: 30 years Gender: Female
• Height: 5’7’’ (170 cm)
• Weight: 136 lb (61.8 kg)
• BMI: ~21.3 kg/m²
• Gravida/Para: G1P0 (assumed based on context)
• Gestational Age: 9 weeks (confirmed pregnancy)
,Chief Complaint
Lower abdominal pain and vaginal spotting for 1 day.
📝 History of Present Illness
The patient is a 30-year-old pregnant woman at approximately 9 weeks of gestation who
presents to the Emergency Room with complaints of lower abdominal pain and vaginal
spotting.
The abdominal pain started suddenly 24 hours prior to presentation. It is localized to the
suprapubic/lower abdominal region, described as crampy, intermittent, and mild to
moderate in intensity. The pain does not radiate and is not associated with shoulder pain or
syncope.
She also reports vaginal spotting, described as light bleeding noticed on wiping, dark red to
brown in color, with no passage of clots or tissue. There is no foul-smelling discharge.
She denies:
• Fever or chills
• Nausea or vomiting
• Dysuria or urinary frequency
• Dizziness or fainting
• Heavy vaginal bleeding
There is no history of trauma, recent intercourse, or strenuous activity.
Obstetric and Gynecologic History
• Last Menstrual Period (LMP): Approximately 9 weeks ago
Document shared on https://www.docsity.com/en/docs/30-years-old-female-with-lower-abdominal-pain-and-vaginal-spotting-full-case-and-soap-note/15576808/
, • Menstrual cycles: Regular, 28–30 days
• Previous pregnancies: None
• History of miscarriages or ectopic pregnancy: None
• Contraceptive use: None prior to conception
• Sexually transmitted infections: Denied
• Pap smear history: Up to date, normal
Past Medical History
No history of:
o Hypertension o
Diabetes
mellitus o Thyroid
disease o Bleeding
disorders
Past Surgical History
No prior surgeries
Drug History
• Prenatal vitamins only
• No known drug allergies
Family History
No family history of:
o Genetic disorders o
Recurrent
miscarriages o
Gynecologic cancers
Pain and Vaginal Spotting Full Case and
Soap Note
2026 Update Real Assignment
Patient Profile
• Name: Not disclosed
• Age: 30 years Gender: Female
• Height: 5’7’’ (170 cm)
• Weight: 136 lb (61.8 kg)
• BMI: ~21.3 kg/m²
• Gravida/Para: G1P0 (assumed based on context)
• Gestational Age: 9 weeks (confirmed pregnancy)
,Chief Complaint
Lower abdominal pain and vaginal spotting for 1 day.
📝 History of Present Illness
The patient is a 30-year-old pregnant woman at approximately 9 weeks of gestation who
presents to the Emergency Room with complaints of lower abdominal pain and vaginal
spotting.
The abdominal pain started suddenly 24 hours prior to presentation. It is localized to the
suprapubic/lower abdominal region, described as crampy, intermittent, and mild to
moderate in intensity. The pain does not radiate and is not associated with shoulder pain or
syncope.
She also reports vaginal spotting, described as light bleeding noticed on wiping, dark red to
brown in color, with no passage of clots or tissue. There is no foul-smelling discharge.
She denies:
• Fever or chills
• Nausea or vomiting
• Dysuria or urinary frequency
• Dizziness or fainting
• Heavy vaginal bleeding
There is no history of trauma, recent intercourse, or strenuous activity.
Obstetric and Gynecologic History
• Last Menstrual Period (LMP): Approximately 9 weeks ago
Document shared on https://www.docsity.com/en/docs/30-years-old-female-with-lower-abdominal-pain-and-vaginal-spotting-full-case-and-soap-note/15576808/
, • Menstrual cycles: Regular, 28–30 days
• Previous pregnancies: None
• History of miscarriages or ectopic pregnancy: None
• Contraceptive use: None prior to conception
• Sexually transmitted infections: Denied
• Pap smear history: Up to date, normal
Past Medical History
No history of:
o Hypertension o
Diabetes
mellitus o Thyroid
disease o Bleeding
disorders
Past Surgical History
No prior surgeries
Drug History
• Prenatal vitamins only
• No known drug allergies
Family History
No family history of:
o Genetic disorders o
Recurrent
miscarriages o
Gynecologic cancers
