Acute Diarrhea Case Study | i-Human NP & Medical Student SOAP Note | 42-Year-Old Gastroenteritis PDF | Traveler's Diarrhea Workup

I HUMAN CASE STUDY - WEEK 5 FOR A 42-
YEAR-OLD MALE PRESENTING WITH
DIARRHEA WITH A SOAP NOTE LATEST
UPDATE WITH EXPERT VALUATION |
DISTINCTION GRADED

,1. General Case Information
g; g;




Case g;title g;& g;summary:
Acute-onset g;watery g;diarrhea g;in g;a g;42-year-old g;man g;— g;evaluation g;includes g;infectious g;causes
g; (bacterial, g;viral, g;parasitic), g;medication g;and g;toxin g;causes, g;inflammatory g;bowel g;disease
g; flare, g;and g;noninfectious g;etiologies. g;Focus g;on g;dehydration g;assessment, g;appropriate g;use g;of
g; diagnostics g;(stool g;testing, g;labs, g;imaging), g;and g;targeted g;therapy g;(fluid g;resuscitation,
g; symptomatic g;care, g;and g;pathogen-directed g;antimicrobials g;when g;indicated).

Reason g;for g;encounter:
“Sudden g;onset g;of g;frequent g;watery g;stools g;for g;3 g;days” g;— g;evaluation g;for g;dehydration, g;infectious g;vs
g; noninfectious g;cause, g;and g;management.

Patient g;demographics:

• Age: g;42 g;years
• Sex: g;Male
• Height g;& g;weight: g;Not g;provided g;(assume g;average g;adult g;for g;dosing g;guidance)
• BMI: g;Not g;provided

Case g;mode: g;Learning g;mode g;(outpatient g;clinic g;with g;lab g;capability)

Case g;location: g;Outpatient g;primary g;care g;clinic g;with g;point-of-care g;testing g;and g;access g;to g;stool
g; studies g;and g;imaging

Attempts g;allowed: g;Unlimited g;(learning)




2. Chief Complaint (CC)
g; g;




“I’ve g;had g;loose g;watery g;stools g;since g;three g;days g;ago g;— g;about g;6 g;to g;8 g;times g;a g;day g;— g;and g;I
feel g;weak.”
g;

, • Onset: g;3 g;days g;ago
• Frequency: g;6–8 g;watery g;stools/day
• Stool g;description: g;Watery, g;no g;frank g;blood g;reported g;initially g;(patient g;should g;be
asked g;again)
g;



• Associated: g;Mild g;abdominal g;cramping, g;nausea, g;decreased g;appetite, g;several g;episodes
of g;vomiting g;the g;first g;day
g;



• Severity: g;Moderate; g;interfering g;with g;work g;and g;daily g;activities




3. History of Present Illness (HPI)
g; g; g; g;




The g;patient g;is g;a g;42-year-old g;man g;who g;developed g;acute g;watery g;diarrhea g;3 g;days g;ago. g;Key
timeline g;and g;exposures:
g;




• First g;day: g;Abrupt g;onset g;of g;nausea, g;2 g;episodes g;of g;nonbloody g;emesis, g;then g;watery
diarrhea g;starting g;later g;that g;day.
g;



• Course: g;Diarrhea g;persistent g;(6–8 g;BMs/day), g;occasional g;urgency, g;mild g;diffuse
cramping, g;no g;tenesmus g;reported.
g;



• Stool: g;No g;gross g;blood g;on g;initial g;history g;(ask g;caregiver g;to g;re-check g;— g;note: g;if g;later
g; blood, g;management g;changes). g;No g;mucus g;reported.
• Systemic g;symptoms: g;Low-grade g;fever g;(T g;max g;~38.0°C) g;first g;48 g;hours, g;now
afebrile; g;subjective g;lightheadedness g;with g;standing.
g;



• Recent g;exposures: g;Ate g;at g;a g;local g;street g;food g;vendor g;2 g;nights g;prior g;to g;illness;
g; two g;coworkers g;had g;“stomach g;bug” g;last g;week. g;No g;recent g;travel g;outside g;the
country g;in g;past g;3 g;months.
g;



• Medications: g;Takes g;an g;NSAID g;PRN g;for g;back g;pain; g;on g;no g;chronic g;antibiotics. g;No
recent g;course g;of g;antibiotics g;in g;last g;3 g;months.
g;



• Underlying g;conditions: g;No g;known g;inflammatory g;bowel g;disease, g;no g;diabetes,
g; no g;immunosuppression.
• Bowel g;habits g;at g;baseline: g;1 g;formed g;stool/day g;prior g;to g;illness.
• Urine g;output/fluids: g;Reduced g;oral g;intake; g;decreased g;urine g;output g;in g;last g;24 g;hours.