IHUMAN CASE STUDY. DAN
JONES, 42-YEAR-OLD. REASON
FOR ENCOUNTER: DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
1. HISTORY
Patient Identification
• Name: Dan Jones
• Age: 42 years
• Gender: Male
• Marital Status: Married
• Occupation: Sales Representative
, • Source of History: Patient (reliable historian)
Chief Complaint (CC)
"I've had diarrhea for the past three days."
History of Present Illness (HPI)
Dan Jones is a 42-year-old male who presents with a three-day
history of diarrhea. He reports the sudden onset of frequent loose,
watery stools occurring approximately seven to eight times per day.
The diarrhea is non-bloody and not associated with mucus. He also
complains of intermittent lower abdominal cramping that usually
occurs before bowel movements and improves afterward.
The patient reports mild nausea but denies vomiting. He has noticed
decreased appetite and has been drinking fluids but feels thirsty
more often than usual. He reports a low-grade fever on the first day
of illness but none since. He denies constipation, black stools, severe
abdominal pain, or recent weight loss.
Dan recalls eating food from a roadside restaurant one day before
the symptoms began. He denies recent travel, antibiotic use,
hospitalization, or contact with anyone known to have similar
symptoms. He has been taking oral fluids and over-the-counter
loperamide with minimal improvement.
OLD CARTS
Onset
Symptoms began suddenly three days ago.
JONES, 42-YEAR-OLD. REASON
FOR ENCOUNTER: DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
1. HISTORY
Patient Identification
• Name: Dan Jones
• Age: 42 years
• Gender: Male
• Marital Status: Married
• Occupation: Sales Representative
, • Source of History: Patient (reliable historian)
Chief Complaint (CC)
"I've had diarrhea for the past three days."
History of Present Illness (HPI)
Dan Jones is a 42-year-old male who presents with a three-day
history of diarrhea. He reports the sudden onset of frequent loose,
watery stools occurring approximately seven to eight times per day.
The diarrhea is non-bloody and not associated with mucus. He also
complains of intermittent lower abdominal cramping that usually
occurs before bowel movements and improves afterward.
The patient reports mild nausea but denies vomiting. He has noticed
decreased appetite and has been drinking fluids but feels thirsty
more often than usual. He reports a low-grade fever on the first day
of illness but none since. He denies constipation, black stools, severe
abdominal pain, or recent weight loss.
Dan recalls eating food from a roadside restaurant one day before
the symptoms began. He denies recent travel, antibiotic use,
hospitalization, or contact with anyone known to have similar
symptoms. He has been taking oral fluids and over-the-counter
loperamide with minimal improvement.
OLD CARTS
Onset
Symptoms began suddenly three days ago.
