I- HUMAN CASE STUDY - WEEK 5 FOR A 42-
v v v v v v v v
YEAR-
OLD MALE PRESENTING WITH DIARRHEA
v v v v v
WITH A SOAP NOTE LATEST UPDATE WIT
v v v v v v
H EXPERT VALUATION
v v
,1. General Case Information
v v
Casevtitlev&vsummary:
v Acute-onsetvwateryvdiarrheavinvav42-year-oldvmanv—
v evaluationvincludesvinfectiousvcausesv(bacterial,vviral,vparasitic),vmedicationvandvtoxinvcauses,vinf
lammatoryvbowelvdiseasevflare,vandvnoninfectiousvetiologies.vFocusvonvdehydrationvassessment,va
ppropriatevusevofvdiagnosticsv(stoolvtesting,vlabs,vimaging),vandvtargetedvtherapyv(fluidvresuscitati
on,vsymptomaticvcare,vandvpathogen-directedvantimicrobialsvwhenvindicated).
Reasonvforvencounter:
“Suddenvonsetvofvfrequentvwateryvstoolsvforv3vdays”v—
v evaluationvforvdehydration,vinfectiousvvsvnoninfectiousvcause,vandvmanagement.
Patientvdemographics:
Age:v42vyears
Sex:vMale
Heightv&vweight:vNotvprovidedv(assumevaveragevadultvforvdosingvguidance)
BMI:vNotvprovided
Casevmode:vLearningvmodev(outpatientvclinicvwithvlabvcapability)
Casevlocation:vOutpatientvprimaryvcarevclinicvwithvpoint-of-
carevtestingvandvaccessvtovstoolvstudiesvandvimaging
Attemptsvallowed:vUnlimitedv(learning)
2. Chief Complaint (CC)
v v
“I’vevhadvloosevwateryvstoolsvsincevthreevdaysvagov—vaboutv6vtov8vtimesvavdayv—vandvIvfeelvweak.”
, Onset:v3vdaysvago
Frequency:v6–8vwateryvstools/day
Stoolvdescription:vWatery,vnovfrankvbloodvreportedvinitiallyv(patientvshouldvbevaskedva
gain)
Associated:vMildvabdominalvcramping,vnausea,vdecreasedvappetite,vseveralvepisodesvofv
vomitingvthevfirstvday
Severity:vModerate;vinterferingvwithvworkvandvdailyvactivities
3. History of Present Illness (HPI)
v v v v
Thevpatientvisvav42-year-
oldvmanvwhovdevelopedvacutevwateryvdiarrheav3vdaysvago.vKeyvtimelinevandvexposures:
Firstvday:vAbruptvonsetvofvnausea,v2vepisodesvofvnonbloodyvemesis,vthenvwateryvdiarrheavs
tartingvlatervthatvday.
Course:vDiarrheavpersistentv(6–
8vBMs/day),voccasionalvurgency,vmildvdiffusevcramping,vnovtenesmusvreported.
Stool:vNovgrossvbloodvonvinitialvhistoryv(askvcaregivervtovre-checkv—
vnote:vifvlatervblood,vmanagementvchanges).vNovmucusvreported.
Systemicvsymptoms:vLow-
gradevfeverv(Tvmaxv~38.0°C)vfirstv48vhours,vnowvafebrile;vsubjectivevlightheadednessv
withvstanding.
Recentvexposures:vAtevatvavlocalvstreetvfoodvvendorv2vnightsvpriorvtovillness;vtwovcowor
kersvhadv“stomachvbug”vlastvweek.vNovrecentvtravelvoutsidevthevcountryvinvpastv3vmonths
.
Medications:vTakesvanvNSAIDvPRNvforvbackvpain;vonvnovchronicvantibiotics.vNovrecentvc
oursevofvantibioticsvinvlastv3vmonths.
Underlyingvconditions:vNovknownvinflammatoryvbowelvdisease,vnovdiabetes,vnovi
mmunosuppression.
Bowelvhabitsvatvbaseline:v1vformedvstool/dayvpriorvtovillness.
Urinevoutput/fluids:vReducedvoralvintake;vdecreasedvurinevoutputvinvlastv24vhours.
v v v v v v v v
YEAR-
OLD MALE PRESENTING WITH DIARRHEA
v v v v v
WITH A SOAP NOTE LATEST UPDATE WIT
v v v v v v
H EXPERT VALUATION
v v
,1. General Case Information
v v
Casevtitlev&vsummary:
v Acute-onsetvwateryvdiarrheavinvav42-year-oldvmanv—
v evaluationvincludesvinfectiousvcausesv(bacterial,vviral,vparasitic),vmedicationvandvtoxinvcauses,vinf
lammatoryvbowelvdiseasevflare,vandvnoninfectiousvetiologies.vFocusvonvdehydrationvassessment,va
ppropriatevusevofvdiagnosticsv(stoolvtesting,vlabs,vimaging),vandvtargetedvtherapyv(fluidvresuscitati
on,vsymptomaticvcare,vandvpathogen-directedvantimicrobialsvwhenvindicated).
Reasonvforvencounter:
“Suddenvonsetvofvfrequentvwateryvstoolsvforv3vdays”v—
v evaluationvforvdehydration,vinfectiousvvsvnoninfectiousvcause,vandvmanagement.
Patientvdemographics:
Age:v42vyears
Sex:vMale
Heightv&vweight:vNotvprovidedv(assumevaveragevadultvforvdosingvguidance)
BMI:vNotvprovided
Casevmode:vLearningvmodev(outpatientvclinicvwithvlabvcapability)
Casevlocation:vOutpatientvprimaryvcarevclinicvwithvpoint-of-
carevtestingvandvaccessvtovstoolvstudiesvandvimaging
Attemptsvallowed:vUnlimitedv(learning)
2. Chief Complaint (CC)
v v
“I’vevhadvloosevwateryvstoolsvsincevthreevdaysvagov—vaboutv6vtov8vtimesvavdayv—vandvIvfeelvweak.”
, Onset:v3vdaysvago
Frequency:v6–8vwateryvstools/day
Stoolvdescription:vWatery,vnovfrankvbloodvreportedvinitiallyv(patientvshouldvbevaskedva
gain)
Associated:vMildvabdominalvcramping,vnausea,vdecreasedvappetite,vseveralvepisodesvofv
vomitingvthevfirstvday
Severity:vModerate;vinterferingvwithvworkvandvdailyvactivities
3. History of Present Illness (HPI)
v v v v
Thevpatientvisvav42-year-
oldvmanvwhovdevelopedvacutevwateryvdiarrheav3vdaysvago.vKeyvtimelinevandvexposures:
Firstvday:vAbruptvonsetvofvnausea,v2vepisodesvofvnonbloodyvemesis,vthenvwateryvdiarrheavs
tartingvlatervthatvday.
Course:vDiarrheavpersistentv(6–
8vBMs/day),voccasionalvurgency,vmildvdiffusevcramping,vnovtenesmusvreported.
Stool:vNovgrossvbloodvonvinitialvhistoryv(askvcaregivervtovre-checkv—
vnote:vifvlatervblood,vmanagementvchanges).vNovmucusvreported.
Systemicvsymptoms:vLow-
gradevfeverv(Tvmaxv~38.0°C)vfirstv48vhours,vnowvafebrile;vsubjectivevlightheadednessv
withvstanding.
Recentvexposures:vAtevatvavlocalvstreetvfoodvvendorv2vnightsvpriorvtovillness;vtwovcowor
kersvhadv“stomachvbug”vlastvweek.vNovrecentvtravelvoutsidevthevcountryvinvpastv3vmonths
.
Medications:vTakesvanvNSAIDvPRNvforvbackvpain;vonvnovchronicvantibiotics.vNovrecentvc
oursevofvantibioticsvinvlastv3vmonths.
Underlyingvconditions:vNovknownvinflammatoryvbowelvdisease,vnovdiabetes,vnovi
mmunosuppression.
Bowelvhabitsvatvbaseline:v1vformedvstool/dayvpriorvtovillness.
Urinevoutput/fluids:vReducedvoralvintake;vdecreasedvurinevoutputvinvlastv24vhours.
