I HUMAN WEEK 7 OF A 25 YEAR OLD FEMALE WITH A SEVERE
PAIN IN LOWER BELLY WITH LOOSE STOOL
Clinical Case Study: Patient Presentation
Patient Profile
Name: Deborah Arnaudin
Age: 25 year-old Female
Occupation: Graphic Designer
Chief Complaint: "I've had this sharp pain in my lower belly for two days, and
it's getting much worse."
History of Present Illness (HPI)
Deborah presents with acute-on-chronic pelvic pain localized to the lower quadrants, primarily on the
right side. She describes the current episode as a sharp, 'stabbing' sensation that began 48 hours ago.
She notes a history of dull, aching pelvic pain over the last six months, which she previously attributed
'bad cramps.'
Associated Symptoms:
• Gastrointestinal: Intermittent nausea without emesis; no changes in bowel habits.
• Genitourinary: Reports increased vaginal discharge over the past week; denies dysuria.
, • Menstrual: Last Menstrual Period (LMP) was 3 weeks ago; she reports her periods have become
increasingly heavy and painful (dysmenorrhea) over the last year. She also mentions occasional
pain during intercourse (dyspareunia).
Past Medical History (PMH) Social History Family History
• Appendectomy (age 14) • Mild • Non-smoker • Social alcohol use • Mother: Endometriosis • Father
Asthma • No known drug allergies • Sexually active; inconsistent Hypertension • Maternal Aunt:
• G0P0 (Never pregnant) barrier protection Ovarian cysts
Physical Examination & Diagnostics
Vital Signs Physical Exam Findings
Temp: 100.2°F (Oral) BP: 118/76 mmHg Abdomen: Soft, but significant tenderness to deep palpatio
HR: 104 bpm (Tachycardic) RR: 18 in bilateral lower quadrants (R > L). Positive voluntary guard
breaths/min SpO2: 99% on RA noted. No rebound tenderness. Bowel sounds present in all
quadrants.
Pelvic: Speculum exam reveals moderate mucopurulent
discharge. Bimanual exam reveals exquisite Cervical Motion
Tenderness (CMT) and bilateral adnexal tenderness.
Laboratory Results
Test Result
Complete Blood Count (CBC) WBC: 13,500/mm³ (Elevated); Hgb: 12.1 g/dL
Comprehensive Metabolic Panel (CMP) All electrolytes and liver enzymes within normal
limits.
Pregnancy Test (Serum hCG) Negative
PAIN IN LOWER BELLY WITH LOOSE STOOL
Clinical Case Study: Patient Presentation
Patient Profile
Name: Deborah Arnaudin
Age: 25 year-old Female
Occupation: Graphic Designer
Chief Complaint: "I've had this sharp pain in my lower belly for two days, and
it's getting much worse."
History of Present Illness (HPI)
Deborah presents with acute-on-chronic pelvic pain localized to the lower quadrants, primarily on the
right side. She describes the current episode as a sharp, 'stabbing' sensation that began 48 hours ago.
She notes a history of dull, aching pelvic pain over the last six months, which she previously attributed
'bad cramps.'
Associated Symptoms:
• Gastrointestinal: Intermittent nausea without emesis; no changes in bowel habits.
• Genitourinary: Reports increased vaginal discharge over the past week; denies dysuria.
, • Menstrual: Last Menstrual Period (LMP) was 3 weeks ago; she reports her periods have become
increasingly heavy and painful (dysmenorrhea) over the last year. She also mentions occasional
pain during intercourse (dyspareunia).
Past Medical History (PMH) Social History Family History
• Appendectomy (age 14) • Mild • Non-smoker • Social alcohol use • Mother: Endometriosis • Father
Asthma • No known drug allergies • Sexually active; inconsistent Hypertension • Maternal Aunt:
• G0P0 (Never pregnant) barrier protection Ovarian cysts
Physical Examination & Diagnostics
Vital Signs Physical Exam Findings
Temp: 100.2°F (Oral) BP: 118/76 mmHg Abdomen: Soft, but significant tenderness to deep palpatio
HR: 104 bpm (Tachycardic) RR: 18 in bilateral lower quadrants (R > L). Positive voluntary guard
breaths/min SpO2: 99% on RA noted. No rebound tenderness. Bowel sounds present in all
quadrants.
Pelvic: Speculum exam reveals moderate mucopurulent
discharge. Bimanual exam reveals exquisite Cervical Motion
Tenderness (CMT) and bilateral adnexal tenderness.
Laboratory Results
Test Result
Complete Blood Count (CBC) WBC: 13,500/mm³ (Elevated); Hgb: 12.1 g/dL
Comprehensive Metabolic Panel (CMP) All electrolytes and liver enzymes within normal
limits.
Pregnancy Test (Serum hCG) Negative
