A 42-Year-Old Male With
Acute Diarrhea – Complete Outpatient
Clinic Case With Labs, Full HPI,
Diagnostics, Differential Diagnosis,
Management Plan & Grading-Rubric Alignment
,i-Human Virtual Patient
Week #5 – Diarrhea Case (2025)
Patient Profile
• Name: Mr. J.T.
• Age: 42 years
• Sex: Male
• Setting: Outpatient primary care clinic
• Chief Complaint: “I’ve had diarrhea for the past 4 days.”
History of Present Illness (HPI)
Mr. J.T. is a 42-year-old male who presents with 4 days of frequent loose stools, occurring 6–
8 times per day. Stools are watery, brown, and non-bloody, associated with abdominal
cramping and urgency. He reports mild nausea but denies vomiting.
Symptoms began 2 days after eating street food at a local festival. He reports subjective fever
and chills on day 1, now resolved. He feels fatigued and notes decreased oral intake due to
fear of worsening diarrhea.
He denies:
• Blood or mucus in stool
• Recent antibiotic use
• Recent international travel
• Sick contacts
• Chronic diarrhea
• Weight loss
• Night sweats
Past Medical History
• Hypertension (diagnosed 5 years ago)
Surgical History
• Appendectomy at age 20
Medications
• Lisinopril 10 mg PO daily
, Allergies
• No known drug allergies (NKDA)
Family History
• Father: Hypertension
• Mother: Type 2 diabetes
• No family history of IBD or colon cancer
Social History
• Works as an accountant
• Married, lives with family
• Denies tobacco or illicit drug use
• Drinks alcohol socially (1–2 drinks/week)
• No recent travel
• Eats outside frequently
Review of Systems (ROS)
• General: Fatigue, mild weakness
• GI: Watery diarrhea, abdominal cramps, nausea
• GU: Decreased urine output
• CV/Resp: Denies chest pain, SOB
• Neuro: No dizziness or syncope
Physical Examination
Vital Signs
• BP: 102/64 mmHg
• HR: 98 bpm
• RR: 18 breaths/min
• Temp: 37.8°C (100.0°F)
• SpO₂: 98% on room air
General
• Alert, mildly ill-appearing, appears dehydrated
HEENT
Acute Diarrhea – Complete Outpatient
Clinic Case With Labs, Full HPI,
Diagnostics, Differential Diagnosis,
Management Plan & Grading-Rubric Alignment
,i-Human Virtual Patient
Week #5 – Diarrhea Case (2025)
Patient Profile
• Name: Mr. J.T.
• Age: 42 years
• Sex: Male
• Setting: Outpatient primary care clinic
• Chief Complaint: “I’ve had diarrhea for the past 4 days.”
History of Present Illness (HPI)
Mr. J.T. is a 42-year-old male who presents with 4 days of frequent loose stools, occurring 6–
8 times per day. Stools are watery, brown, and non-bloody, associated with abdominal
cramping and urgency. He reports mild nausea but denies vomiting.
Symptoms began 2 days after eating street food at a local festival. He reports subjective fever
and chills on day 1, now resolved. He feels fatigued and notes decreased oral intake due to
fear of worsening diarrhea.
He denies:
• Blood or mucus in stool
• Recent antibiotic use
• Recent international travel
• Sick contacts
• Chronic diarrhea
• Weight loss
• Night sweats
Past Medical History
• Hypertension (diagnosed 5 years ago)
Surgical History
• Appendectomy at age 20
Medications
• Lisinopril 10 mg PO daily
, Allergies
• No known drug allergies (NKDA)
Family History
• Father: Hypertension
• Mother: Type 2 diabetes
• No family history of IBD or colon cancer
Social History
• Works as an accountant
• Married, lives with family
• Denies tobacco or illicit drug use
• Drinks alcohol socially (1–2 drinks/week)
• No recent travel
• Eats outside frequently
Review of Systems (ROS)
• General: Fatigue, mild weakness
• GI: Watery diarrhea, abdominal cramps, nausea
• GU: Decreased urine output
• CV/Resp: Denies chest pain, SOB
• Neuro: No dizziness or syncope
Physical Examination
Vital Signs
• BP: 102/64 mmHg
• HR: 98 bpm
• RR: 18 breaths/min
• Temp: 37.8°C (100.0°F)
• SpO₂: 98% on room air
General
• Alert, mildly ill-appearing, appears dehydrated
HEENT
