i-Human Case Analysis:Week #7 on 25- Year-Old
Female Presenting: Evaluation of Loose Stools
in an Outpatient Clinic With Laboratory
Capabilities for Exam Submission Walden
University NB REAL CASE
Chief Complaint: Loose stools
Patient: 25-year-old female
Height: 5’4” (163 cm)
Weight: 128 lb (58.2 kg)
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
, HISTORY OF PRESENT ILLNESS (HPI)
Clinician–Patient Dialogue
Clinician: Hello, I’m going to ask you some questions to better understand
what’s been going on. What brings you in today?
Patient: I’ve been having loose stools for the past few days, and it’s starting to
worry me.
Clinician: When did the loose stools first begin?
Patient: About four days ago.
Clinician: How would you describe the stools—are they watery, soft, or just more
frequent than usual?
Patient: They’re mostly watery and definitely looser than normal.
Clinician: How many bowel movements are you having per day?
Patient: Around five to six times a day.
Clinician: Is this more frequent than your normal bowel pattern?
Patient: Yes, normally I go once a day.
Clinician: Have you noticed any blood or mucus in your stool?
Patient: No blood, but sometimes it looks a little slimy.
Clinician: Do you experience any abdominal pain or cramping?
Patient: Yes, I get cramping before I need to go, and it feels better afterward.
Clinician: On a scale of 0 to 10, how severe is the abdominal pain at its worst?
Patient: Maybe a 4 or 5.
Clinician: Have you had any nausea or vomiting?
Patient: I’ve felt a little nauseous, but I haven’t vomited.
Clinician: Have you had a fever or chills?
Patient: I felt slightly warm the first day, but I didn’t check my temperature.
Clinician: Have you noticed any recent weight loss?
Patient: No, my weight has stayed the same.
Female Presenting: Evaluation of Loose Stools
in an Outpatient Clinic With Laboratory
Capabilities for Exam Submission Walden
University NB REAL CASE
Chief Complaint: Loose stools
Patient: 25-year-old female
Height: 5’4” (163 cm)
Weight: 128 lb (58.2 kg)
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
, HISTORY OF PRESENT ILLNESS (HPI)
Clinician–Patient Dialogue
Clinician: Hello, I’m going to ask you some questions to better understand
what’s been going on. What brings you in today?
Patient: I’ve been having loose stools for the past few days, and it’s starting to
worry me.
Clinician: When did the loose stools first begin?
Patient: About four days ago.
Clinician: How would you describe the stools—are they watery, soft, or just more
frequent than usual?
Patient: They’re mostly watery and definitely looser than normal.
Clinician: How many bowel movements are you having per day?
Patient: Around five to six times a day.
Clinician: Is this more frequent than your normal bowel pattern?
Patient: Yes, normally I go once a day.
Clinician: Have you noticed any blood or mucus in your stool?
Patient: No blood, but sometimes it looks a little slimy.
Clinician: Do you experience any abdominal pain or cramping?
Patient: Yes, I get cramping before I need to go, and it feels better afterward.
Clinician: On a scale of 0 to 10, how severe is the abdominal pain at its worst?
Patient: Maybe a 4 or 5.
Clinician: Have you had any nausea or vomiting?
Patient: I’ve felt a little nauseous, but I haven’t vomited.
Clinician: Have you had a fever or chills?
Patient: I felt slightly warm the first day, but I didn’t check my temperature.
Clinician: Have you noticed any recent weight loss?
Patient: No, my weight has stayed the same.
