YEAR-OLD FEMALE WITH LOOSE STOOLS —
(2026) LOCATION: OUTPATIENT CLINIC WITH
LAB CAPABILITIES (WALDEN UNIVERSITY)
Reason for encounter:
Recurrent loose stools for 4 days, worse frequency, mild lightheadedness.
Patient demographics:
Age: 25 years
Sex: Female
Height: 5′5″ (165 cm)
Weight: 135 lb (61 kg)
BMI: 22.3 kg/m²
,Case mode: Learning mode
Case location: Outpatient primary care clinic with stat lab and stool testing
available
Attempts allowed: Unlimited (learning)
2. Chief Complaint (CC)
“I’ve had loose stools and cramping for four days and it’s not getting better.”
Onset: 4 days ago
Stool frequency: 6–8 loose/watery stools per day
Character: Watery, no frank blood reported initially (patient uncertain about
small streaks yesterday)
Associated: Lower abdominal cramps, urgency, mild nausea, decreased
appetite, lightheaded when standing
Severity: Moderate; interfering with work and sleep
3. History of Present Illness (HPI)
A previously healthy 25-year-old female reports acute onset watery diarrhea 4 days
ago after returning from a weekend trip to a neighboring state where she ate local
street food. Initially 3–4 stools/day, now 6–8/day. She describes crampy
periumbilical and lower abdominal pain that eases after defecation. She endorses
mild nausea without vomiting.
, She had subjective fever (up to ~38.0°C / 100.4°F) on day 1 that resolved
spontaneously. Yesterday she noticed a few streaks of red in stool once — she is
uncertain. No tenesmus, no prolonged bleeding. She denies recent antibiotic use,
NSAID overuse, or new medications. No weight loss or chronic GI symptoms. No
known sick contacts at home. Sexual history: monogamous, denies recent receptive
anal intercourse. Oral contraceptive user. No personal or family history of
inflammatory bowel disease.
She has been drinking mostly water but avoided solids; she reports feeling
lightheaded when standing and has produced fewer wet diapers (possible mild
volume depletion).
4. Past Medical History (PMH)
Generally healthy
No chronic GI disease
Up to date on immunizations
5. Medications & Allergies
Medications:
Combined oral contraceptive (ethinyl estradiol + levonorgestrel) daily