18-Year-Old Patient Reason for Encounter - Passed Out | Comprehensive iHuman Case Study 18-Year-Old
Patient
Patient Information:
Age: 18 years old
Gender: Male
Height: 6'0" (183 cm)
Weight: 222.0 lbs (100.9 kg)
BMI: 30.13 (calculated using BMI formula)
o BMI Formula: Weight (kg) / Height (m)²
o BMI Calculation: 100.9 / (1.83 m)² = 100..3489 ≈ 30.13
, Chief Complaint: Passed out (syncope)
Reason for Encounter:
The patient presents with a complaint of passing out (syncope).
This event occurred recently, prompting the patient to seek medical attention.
The syncope episode could be indicative of an underlying medical condition requiring
thorough evaluation.
History of Present Illness (HPI) Questions and Patient’s Response
1. What were you doing when the loose stools started?
"I had just eaten lunch and then went back to my work."
2. How long have you been experiencing loose stools?
"It’s been happening for about a week now."
3. How often are you having loose stools?
"I have them 3-4 times a day, sometimes more."
4. Have you noticed any patterns or triggers for your loose stools?
"It seems to happen more after I eat, especially if I eat something spicy or greasy."
5. Have you had any similar episodes of loose stools in the past?
"No, this is the first time I’ve had this happen."
6. Are there any other gastrointestinal symptoms, such as nausea, bloating, or cramping?
"I’ve had some mild cramping and bloating, but no nausea or vomiting."
7. Have you experienced any changes in your appetite or weight recently?
, "No, my appetite is normal, and I haven’t noticed any weight changes."
8. Do you feel fatigued, dehydrated, or weak due to the loose stools?
"I’ve felt a little tired, but not excessively. I drink plenty of water."
9. Have you been experiencing any fever or chills?
"No, I haven’t had any fever or chills."
10. What is your diet like? Have you had any recent changes?
"I usually eat a balanced diet, but I’ve been eating out more recently, especially fast food."
11. Do you drink alcohol, caffeine, or any sugary beverages?
"I drink coffee every morning, and I have some soda or juice throughout the day."
12. Have you been taking any new medications, vitamins, or supplements?
"No, I haven’t started any new medications or supplements recently."
13. Have you had any recent infections or illnesses?
"I haven’t been sick lately."
14. Have you recently traveled to any places where you could have been exposed to
contaminated food or water?
"No, I haven’t traveled recently."
15. Do you have any known food intolerances, like lactose or gluten?
"No, I don’t have any known food allergies or intolerances."
16. Do you feel more stressed or anxious than usual lately?
"I’ve been a little stressed with work, but nothing major."