REAL CASE STUDY JAN 2026 WEEK#7 ASSIGNMENT
i-Human Case Study Week 7 Assignment |
Evaluation of Loose Stools in a 25-Year-Old
Female | Walden University (2026)
Patient Information
• Age: 25 years
• Gender: Not specified in the title (likely male or female)
• Height: 5'4" (163 cm)
• Weight: 58.2 kg
Chief Complaint:
,REAL CASE STUDY JAN 2026 WEEK#7 ASSIGNMENT
• Reason for Encounter: Loose stools
History of Present Illness (HPI)
Patient–Clinician Dialogue
Clinician: “When did you first notice your diarrhea?”
Patient: “It started about three days ago, shortly after returning from a trip to Mexico. At first, it
was just a little loose stool, but it quickly became watery and frequent.”
Clinician: “How often are you having bowel movements?”
Patient: “Six to eight times a day. Sometimes I have to rush to the bathroom; I can’t hold it.”
Clinician: “Have you noticed blood in your stools?”
Patient: “No, I haven’t seen any blood.”
Clinician: “Any mucus in your stool?”
Patient: “Yes, I noticed some mucus a couple of times.”
Clinician: “Do you have abdominal pain?”
Patient: “Yes, cramping in my lower abdomen, especially before I go to the bathroom.”
Clinician: “Have you had nausea or vomiting?”
Patient: “I vomited once, two days ago. It wasn’t severe, just once.”
Clinician: “Any fevers, chills, or body aches?”
Patient: “Yes, mild fever and chills. I’ve felt tired and weak.”
Clinician: “Have you lost any weight recently?”
Patient: “No.”
Clinician: “Any recent antibiotics?”
Patient: “No.”
Clinician: “Has anyone around you been sick?”
Patient: “No, I don’t know anyone else who is sick.”
Clinician: “Do you drink enough fluids?”
Patient: “I try, but I haven’t been drinking enough. My mouth feels dry sometimes.”
•
, REAL CASE STUDY JAN 2026 WEEK#7 ASSIGNMENT
Family History
• Noncontributory
Social History
• Recent travel to Mexico
• Diet includes occasional street foods while traveling
• Non-smoker, does not consume alcohol
• No recreational drug use
Physical Examination
• General Appearance: Fatigued, mildly ill-appearing
• Vital Signs:
o Temp: 100.4°F
(38°C) o HR: 92 bpm o
BP: 110/70 mmHg o
RR: 18/min
• Skin: Slightly dry mucous membranes, no rash
• HEENT: Dry lips, oropharynx clear
• Abdomen: Soft, mild tenderness in lower quadrants, normoactive bowel sounds, no
rebound tenderness or guarding
• Cardiovascular: Regular rate and rhythm
• Respiratory: Clear to auscultation bilaterally
• Extremities: No edema
• Neurological: Alert and oriented x3, cranial nerves intact
Hydration Status: Slight dehydration evidenced by dry mucous membranes and mild fatigue
Laboratory and Diagnostic Workup
Test Result Notes
CBC WBC 11,000/µL Mild leukocytosis, consistent with infection
CMP BUN 24 mg/dL Slight dehydration
Electrolytes Na/K/Cl normal Monitor for ongoing fluid loss
Stool culture Pending For bacterial pathogens (E. coli, Salmonella, Shigella)
Stool O&P Pending To rule out Giardia, Entamoeba
Occult blood Negative No overt GI bleeding
i-Human Case Study Week 7 Assignment |
Evaluation of Loose Stools in a 25-Year-Old
Female | Walden University (2026)
Patient Information
• Age: 25 years
• Gender: Not specified in the title (likely male or female)
• Height: 5'4" (163 cm)
• Weight: 58.2 kg
Chief Complaint:
,REAL CASE STUDY JAN 2026 WEEK#7 ASSIGNMENT
• Reason for Encounter: Loose stools
History of Present Illness (HPI)
Patient–Clinician Dialogue
Clinician: “When did you first notice your diarrhea?”
Patient: “It started about three days ago, shortly after returning from a trip to Mexico. At first, it
was just a little loose stool, but it quickly became watery and frequent.”
Clinician: “How often are you having bowel movements?”
Patient: “Six to eight times a day. Sometimes I have to rush to the bathroom; I can’t hold it.”
Clinician: “Have you noticed blood in your stools?”
Patient: “No, I haven’t seen any blood.”
Clinician: “Any mucus in your stool?”
Patient: “Yes, I noticed some mucus a couple of times.”
Clinician: “Do you have abdominal pain?”
Patient: “Yes, cramping in my lower abdomen, especially before I go to the bathroom.”
Clinician: “Have you had nausea or vomiting?”
Patient: “I vomited once, two days ago. It wasn’t severe, just once.”
Clinician: “Any fevers, chills, or body aches?”
Patient: “Yes, mild fever and chills. I’ve felt tired and weak.”
Clinician: “Have you lost any weight recently?”
Patient: “No.”
Clinician: “Any recent antibiotics?”
Patient: “No.”
Clinician: “Has anyone around you been sick?”
Patient: “No, I don’t know anyone else who is sick.”
Clinician: “Do you drink enough fluids?”
Patient: “I try, but I haven’t been drinking enough. My mouth feels dry sometimes.”
•
, REAL CASE STUDY JAN 2026 WEEK#7 ASSIGNMENT
Family History
• Noncontributory
Social History
• Recent travel to Mexico
• Diet includes occasional street foods while traveling
• Non-smoker, does not consume alcohol
• No recreational drug use
Physical Examination
• General Appearance: Fatigued, mildly ill-appearing
• Vital Signs:
o Temp: 100.4°F
(38°C) o HR: 92 bpm o
BP: 110/70 mmHg o
RR: 18/min
• Skin: Slightly dry mucous membranes, no rash
• HEENT: Dry lips, oropharynx clear
• Abdomen: Soft, mild tenderness in lower quadrants, normoactive bowel sounds, no
rebound tenderness or guarding
• Cardiovascular: Regular rate and rhythm
• Respiratory: Clear to auscultation bilaterally
• Extremities: No edema
• Neurological: Alert and oriented x3, cranial nerves intact
Hydration Status: Slight dehydration evidenced by dry mucous membranes and mild fatigue
Laboratory and Diagnostic Workup
Test Result Notes
CBC WBC 11,000/µL Mild leukocytosis, consistent with infection
CMP BUN 24 mg/dL Slight dehydration
Electrolytes Na/K/Cl normal Monitor for ongoing fluid loss
Stool culture Pending For bacterial pathogens (E. coli, Salmonella, Shigella)
Stool O&P Pending To rule out Giardia, Entamoeba
Occult blood Negative No overt GI bleeding
