IHUMAN CASE STUDY. 42-YEAR-
OLD, DAN JONES. REASON FOR
ENCOUNTER: DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
1. Patient Demographics & Identifying Data
• Name: Dan Jones
• Age: 42 years old
• Gender: Male
, • Date of Visit: __________________
• Source of History: Patient (reliable historian)
• Accompanied By: Wife
• Race/Ethnicity: Not specified
• Marital Status: Married
• Occupation: Restaurant Manager
• Primary Language: English
• Chief Concern: Persistent diarrhea associated with abdominal cramping
and frequent bowel movements over the past several days.
• Reason for Encounter: Diarrhea.
• Mode of Arrival: Presented to the outpatient clinic accompanied by his
wife because of worsening diarrhea and concern about dehydration.
• Level of Consciousness: Alert, awake, and fully oriented to person, place,
time, and situation.
• General Appearance: Well-developed, well-nourished middle-aged male
who appears his stated age. He looks mildly fatigued but is not in acute
distress. He is able to answer questions appropriately and occasionally
shifts in his seat because of abdominal cramping.
• Reliability of Information: History is considered reliable. The patient
provides a clear, detailed, and consistent description of the onset,
progression, and severity of his symptoms.
2. Chief Complaint (CC)
"I've had diarrhea for the past three days. I'm going to the bathroom almost
every hour, my stomach keeps cramping, and I'm worried because I feel weak
and can't seem to keep up with the fluid I'm losing."
OLD, DAN JONES. REASON FOR
ENCOUNTER: DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
1. Patient Demographics & Identifying Data
• Name: Dan Jones
• Age: 42 years old
• Gender: Male
, • Date of Visit: __________________
• Source of History: Patient (reliable historian)
• Accompanied By: Wife
• Race/Ethnicity: Not specified
• Marital Status: Married
• Occupation: Restaurant Manager
• Primary Language: English
• Chief Concern: Persistent diarrhea associated with abdominal cramping
and frequent bowel movements over the past several days.
• Reason for Encounter: Diarrhea.
• Mode of Arrival: Presented to the outpatient clinic accompanied by his
wife because of worsening diarrhea and concern about dehydration.
• Level of Consciousness: Alert, awake, and fully oriented to person, place,
time, and situation.
• General Appearance: Well-developed, well-nourished middle-aged male
who appears his stated age. He looks mildly fatigued but is not in acute
distress. He is able to answer questions appropriately and occasionally
shifts in his seat because of abdominal cramping.
• Reliability of Information: History is considered reliable. The patient
provides a clear, detailed, and consistent description of the onset,
progression, and severity of his symptoms.
2. Chief Complaint (CC)
"I've had diarrhea for the past three days. I'm going to the bathroom almost
every hour, my stomach keeps cramping, and I'm worried because I feel weak
and can't seem to keep up with the fluid I'm losing."
