Comprehensive iHuman Case Study 25-Year-Old
Female with Loose Stool .pdf Case
Exam
i-Human Comprehensive Case Study
Patient: 25-Year-Old Female
Chief Complaint: “I’ve had loose stools for the past few days.”
Patient Introduction
,A 25-year-old female presents to the outpatient clinic
complaining of loose stools for several days. She appears mildly
uncomfortable but is in no acute distress.
History of Present Illness (HPI)
The patient reports 3–4 days of loose, watery stools, occurring
4–6 times per day. Stools are non-bloody, non-mucoid, and not
foul-smelling. She reports mild lower abdominal cramping
that improves after bowel movements.
She denies:
• Fever or chills
• Nausea or vomiting
• Hematochezia or melena
• Recent antibiotic use
• Recent travel
• Known sick contacts
She reports eating food from a local fast-food restaurant two
days prior to symptom onset. She is able to tolerate oral fluids
but feels mildly fatigued.
Symptoms are worsened by eating and relieved by bowel
movements. She has not tried any medications.
Review of Systems (ROS)
, General: Mild fatigue, no fever, no weight loss
HEENT: No headache, no sore throat
Cardiovascular: No chest pain, no palpitations
Respiratory: No cough, no shortness of breath
Gastrointestinal:
• Positive: loose stools, mild abdominal cramping
• Negative: nausea, vomiting, blood in stool, constipation
Genitourinary: No dysuria, no vaginal discharge
Musculoskeletal: No joint pain
Neurological: No dizziness, no weakness
Skin: No rash
Psychiatric: No anxiety or depression
Past Medical History (PMH)
• No chronic illnesses
Past Surgical History (PSH)
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Family History
Female with Loose Stool .pdf Case
Exam
i-Human Comprehensive Case Study
Patient: 25-Year-Old Female
Chief Complaint: “I’ve had loose stools for the past few days.”
Patient Introduction
,A 25-year-old female presents to the outpatient clinic
complaining of loose stools for several days. She appears mildly
uncomfortable but is in no acute distress.
History of Present Illness (HPI)
The patient reports 3–4 days of loose, watery stools, occurring
4–6 times per day. Stools are non-bloody, non-mucoid, and not
foul-smelling. She reports mild lower abdominal cramping
that improves after bowel movements.
She denies:
• Fever or chills
• Nausea or vomiting
• Hematochezia or melena
• Recent antibiotic use
• Recent travel
• Known sick contacts
She reports eating food from a local fast-food restaurant two
days prior to symptom onset. She is able to tolerate oral fluids
but feels mildly fatigued.
Symptoms are worsened by eating and relieved by bowel
movements. She has not tried any medications.
Review of Systems (ROS)
, General: Mild fatigue, no fever, no weight loss
HEENT: No headache, no sore throat
Cardiovascular: No chest pain, no palpitations
Respiratory: No cough, no shortness of breath
Gastrointestinal:
• Positive: loose stools, mild abdominal cramping
• Negative: nausea, vomiting, blood in stool, constipation
Genitourinary: No dysuria, no vaginal discharge
Musculoskeletal: No joint pain
Neurological: No dizziness, no weakness
Skin: No rash
Psychiatric: No anxiety or depression
Past Medical History (PMH)
• No chronic illnesses
Past Surgical History (PSH)
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Family History
