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
• 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
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/
, 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
Social History
• Non-smoker
• No alcohol use
• No illicit drug use
• Lives with partner
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
• 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
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/
, 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
Social History
• Non-smoker
• No alcohol use
• No illicit drug use
• Lives with partner
