Week #7 Case Analysis: on 25- Year-Old Female
Presenting: Loose Stools in an Outpatient Clinic
With Laboratory Capabilities for Exam
Submission Walden University
Chief Complaint: Loose stools
Patient: 25-year-old female
Height: 5’4” (163 cm)
Weight: 128 lb (58.2 kg)
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
,HISTORY OF PRESENT ILLNESS (HPI)
Clinician–Patient Dialogue
Clinician: Hello, I’m going to ask you some questions to better understand what’s
been going on. What brings you in today?
Patient: I’ve been having loose stools for the past few days, and it’s starting to
worry me.
Clinician: When did the loose stools first begin? Patient:
About four days ago.
Clinician: How would you describe the stools—are they watery, soft, or just more
frequent than usual?
Patient: They’re mostly watery and definitely looser than normal.
Clinician: How many bowel movements are you having per day? Patient:
Around five to six times a day.
Clinician: Is this more frequent than your normal bowel pattern? Patient:
Yes, normally I go once a day.
Clinician: Have you noticed any blood or mucus in your stool? Patient:
No blood, but sometimes it looks a little slimy.
Clinician: Do you experience any abdominal pain or cramping?
Patient: Yes, I get cramping before I need to go, and it feels better afterward.
Clinician: On a scale of 0 to 10, how severe is the abdominal pain at its worst?
Patient: Maybe a 4 or 5.
Clinician: Have you had any nausea or vomiting?
Patient: I’ve felt a little nauseous, but I haven’t vomited.
Clinician: Have you had a fever or chills?
Patient: I felt slightly warm the first day, but I didn’t check my temperature.
Clinician: Have you noticed any recent weight loss?
Document shared on https://www.docsity.com/en/docs/week-7-case-analysis-on-25-year-old-female-presenting-loose-stools-in-an-outpatient-cl/15419238/
, Patient: No, my weight has stayed the same.
Clinician: Any recent travel, especially out of the country? Patient:
No, I haven’t traveled recently.
Clinician: Have you eaten any undercooked food, street food, or food that
seemed spoiled?
Patient: I did eat takeout chicken about a day before this started.
Clinician: Has anyone around you been sick with similar symptoms? Patient:
Yes, my roommate had diarrhea earlier this week.
Clinician: Are you able to keep fluids down?
Patient: Yes, I’m drinking water, but I feel a bit dehydrated.
Clinician: Do you feel dizzy or lightheaded?
Patient: A little, especially when I stand up quickly.
Clinician: Have you taken any medications to help with the diarrhea?
Patient: I tried over-the-counter loperamide once, but it didn’t help much.
Clinician: Are you currently taking any antibiotics or new medications? Patient:
No antibiotics and no new medications.
Clinician: Have you had similar episodes in the past?
Patient: Once or twice, but never this bad.
Clinician: Does anything make your symptoms better or worse? Patient:
Eating seems to make it worse. Rest helps a little.
Clinician: Do the symptoms wake you up at night?
Patient: Yes, I’ve had to get up twice during the night to use the bathroom.
REVIEW OF SYSTEMS (ROS)
• General: Mild fatigue, no significant weight change
• Gastrointestinal: Watery diarrhea, abdominal cramping, mild nausea
• Cardiovascular: No chest pain, no palpitations
• Respiratory: No cough or shortness of breath
Presenting: Loose Stools in an Outpatient Clinic
With Laboratory Capabilities for Exam
Submission Walden University
Chief Complaint: Loose stools
Patient: 25-year-old female
Height: 5’4” (163 cm)
Weight: 128 lb (58.2 kg)
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
,HISTORY OF PRESENT ILLNESS (HPI)
Clinician–Patient Dialogue
Clinician: Hello, I’m going to ask you some questions to better understand what’s
been going on. What brings you in today?
Patient: I’ve been having loose stools for the past few days, and it’s starting to
worry me.
Clinician: When did the loose stools first begin? Patient:
About four days ago.
Clinician: How would you describe the stools—are they watery, soft, or just more
frequent than usual?
Patient: They’re mostly watery and definitely looser than normal.
Clinician: How many bowel movements are you having per day? Patient:
Around five to six times a day.
Clinician: Is this more frequent than your normal bowel pattern? Patient:
Yes, normally I go once a day.
Clinician: Have you noticed any blood or mucus in your stool? Patient:
No blood, but sometimes it looks a little slimy.
Clinician: Do you experience any abdominal pain or cramping?
Patient: Yes, I get cramping before I need to go, and it feels better afterward.
Clinician: On a scale of 0 to 10, how severe is the abdominal pain at its worst?
Patient: Maybe a 4 or 5.
Clinician: Have you had any nausea or vomiting?
Patient: I’ve felt a little nauseous, but I haven’t vomited.
Clinician: Have you had a fever or chills?
Patient: I felt slightly warm the first day, but I didn’t check my temperature.
Clinician: Have you noticed any recent weight loss?
Document shared on https://www.docsity.com/en/docs/week-7-case-analysis-on-25-year-old-female-presenting-loose-stools-in-an-outpatient-cl/15419238/
, Patient: No, my weight has stayed the same.
Clinician: Any recent travel, especially out of the country? Patient:
No, I haven’t traveled recently.
Clinician: Have you eaten any undercooked food, street food, or food that
seemed spoiled?
Patient: I did eat takeout chicken about a day before this started.
Clinician: Has anyone around you been sick with similar symptoms? Patient:
Yes, my roommate had diarrhea earlier this week.
Clinician: Are you able to keep fluids down?
Patient: Yes, I’m drinking water, but I feel a bit dehydrated.
Clinician: Do you feel dizzy or lightheaded?
Patient: A little, especially when I stand up quickly.
Clinician: Have you taken any medications to help with the diarrhea?
Patient: I tried over-the-counter loperamide once, but it didn’t help much.
Clinician: Are you currently taking any antibiotics or new medications? Patient:
No antibiotics and no new medications.
Clinician: Have you had similar episodes in the past?
Patient: Once or twice, but never this bad.
Clinician: Does anything make your symptoms better or worse? Patient:
Eating seems to make it worse. Rest helps a little.
Clinician: Do the symptoms wake you up at night?
Patient: Yes, I’ve had to get up twice during the night to use the bathroom.
REVIEW OF SYSTEMS (ROS)
• General: Mild fatigue, no significant weight change
• Gastrointestinal: Watery diarrhea, abdominal cramping, mild nausea
• Cardiovascular: No chest pain, no palpitations
• Respiratory: No cough or shortness of breath
