Case study M94 W5 Soap Note ID: S. L is a 24-year-old female Cc: “Acute lower abdominal

Case study

M94 W5 Soap Note

ID: S. L is a 24-year-old female

Cc: “Acute lower abdominal pain for the past 1 week”

Subjective:

She reports sharp, intermittent pain in the lower abdomen, worsening with movement.

Associated symptoms: nausea, mild fever, and bloating.

Denies vomiting or changes in bowel movements.

LMP: March 1, 2025. She denies irregular menstrual cycles.

No history of similar pain.

Abdominal exam: Tenderness in the lower abdomen, no rebound tenderness, normal bowel sounds

Pelvic exam: No abnormal discharge; mild cervical motion tenderness

Labs and so on…..

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