I- HUMAN CASE STUDY - WEEK 5 FOR A 42-
YEAR-OLD MALE PRESENTING WITH
DIARRHEA WITH A SOAP NOTE LATEST
UPDATE WITH EXPERT VALUATION
,1. General Case Information
Case title & summary:
Acute-onset watery diarrhea in a 42-year-old man — evaluation includes infectious causes
(bacterial, viral, parasitic), medication and toxin causes, inflammatory bowel disease flare, and
noninfectious etiologies. Focus on dehydration assessment, appropriate use of diagnostics (stool
testing, labs, imaging), and targeted therapy (fluid resuscitation, symptomatic care, and
pathogen-directed antimicrobials when indicated).
Reason for encounter:
“Sudden onset of frequent watery stools for 3 days” — evaluation for dehydration, infectious vs
noninfectious cause, and management.
Patient demographics:
• Age: 42 years
• Sex: Male
• Height & weight: Not provided (assume average adult for dosing guidance)
• BMI: Not provided
Case mode: Learning mode (outpatient clinic with lab capability)
Case location: Outpatient primary care clinic with point-of-care testing and access to stool
studies and imaging
Attempts allowed: Unlimited (learning)
2. Chief Complaint (CC)
“I’ve had loose watery stools since three days ago — about 6 to 8 times a day — and I feel
weak.”
, • Onset: 3 days ago
• Frequency: 6–8 watery stools/day
• Stool description: Watery, no frank blood reported initially (patient should be asked
again)
• Associated: Mild abdominal cramping, nausea, decreased appetite, several episodes of
vomiting the first day
• Severity: Moderate; interfering with work and daily activities
3. History of Present Illness (HPI)
The patient is a 42-year-old man who developed acute watery diarrhea 3 days ago. Key
timeline and exposures:
• First day: Abrupt onset of nausea, 2 episodes of nonbloody emesis, then watery diarrhea
starting later that day.
• Course: Diarrhea persistent (6–8 BMs/day), occasional urgency, mild diffuse cramping,
no tenesmus reported.
• Stool: No gross blood on initial history (ask caregiver to re-check — note: if later blood,
management changes). No mucus reported.
• Systemic symptoms: Low-grade fever (T max ~38.0°C) first 48 hours, now afebrile;
subjective lightheadedness with standing.
• Recent exposures: Ate at a local street food vendor 2 nights prior to illness; two
coworkers had “stomach bug” last week. No recent travel outside the country in past 3
months.
• Medications: Takes an NSAID PRN for back pain; on no chronic antibiotics. No recent
course of antibiotics in last 3 months.
• Underlying conditions: No known inflammatory bowel disease, no diabetes, no
immunosuppression.
• Bowel habits at baseline: 1 formed stool/day prior to illness.
• Urine output/fluids: Reduced oral intake; decreased urine output in last 24 hours.
YEAR-OLD MALE PRESENTING WITH
DIARRHEA WITH A SOAP NOTE LATEST
UPDATE WITH EXPERT VALUATION
,1. General Case Information
Case title & summary:
Acute-onset watery diarrhea in a 42-year-old man — evaluation includes infectious causes
(bacterial, viral, parasitic), medication and toxin causes, inflammatory bowel disease flare, and
noninfectious etiologies. Focus on dehydration assessment, appropriate use of diagnostics (stool
testing, labs, imaging), and targeted therapy (fluid resuscitation, symptomatic care, and
pathogen-directed antimicrobials when indicated).
Reason for encounter:
“Sudden onset of frequent watery stools for 3 days” — evaluation for dehydration, infectious vs
noninfectious cause, and management.
Patient demographics:
• Age: 42 years
• Sex: Male
• Height & weight: Not provided (assume average adult for dosing guidance)
• BMI: Not provided
Case mode: Learning mode (outpatient clinic with lab capability)
Case location: Outpatient primary care clinic with point-of-care testing and access to stool
studies and imaging
Attempts allowed: Unlimited (learning)
2. Chief Complaint (CC)
“I’ve had loose watery stools since three days ago — about 6 to 8 times a day — and I feel
weak.”
, • Onset: 3 days ago
• Frequency: 6–8 watery stools/day
• Stool description: Watery, no frank blood reported initially (patient should be asked
again)
• Associated: Mild abdominal cramping, nausea, decreased appetite, several episodes of
vomiting the first day
• Severity: Moderate; interfering with work and daily activities
3. History of Present Illness (HPI)
The patient is a 42-year-old man who developed acute watery diarrhea 3 days ago. Key
timeline and exposures:
• First day: Abrupt onset of nausea, 2 episodes of nonbloody emesis, then watery diarrhea
starting later that day.
• Course: Diarrhea persistent (6–8 BMs/day), occasional urgency, mild diffuse cramping,
no tenesmus reported.
• Stool: No gross blood on initial history (ask caregiver to re-check — note: if later blood,
management changes). No mucus reported.
• Systemic symptoms: Low-grade fever (T max ~38.0°C) first 48 hours, now afebrile;
subjective lightheadedness with standing.
• Recent exposures: Ate at a local street food vendor 2 nights prior to illness; two
coworkers had “stomach bug” last week. No recent travel outside the country in past 3
months.
• Medications: Takes an NSAID PRN for back pain; on no chronic antibiotics. No recent
course of antibiotics in last 3 months.
• Underlying conditions: No known inflammatory bowel disease, no diabetes, no
immunosuppression.
• Bowel habits at baseline: 1 formed stool/day prior to illness.
• Urine output/fluids: Reduced oral intake; decreased urine output in last 24 hours.
