2025 I-HUMAN WK #7
REASON FOR
ENCOUNTER:
DIARRHEA FOR 3
DAYS 4Y/O LEAKING
STOOL BIPOLAR
DISORDERS
,
, lOMoAR cPSD| 46020670
Week 5 Ihuman Assessment
History (Subjective Assessment)
Reason for encounter: Diarrhea for 3 days
HPI: Dylan Barton, is a 42-year-old male marketing partner, has been experiencing symptoms
for the past three days, which include the presence of blood in his stool, chills, headache,
tiredness, fever, stomach pain, and a decrease in appetite. The symptoms of explosive diarrhea
persist for a duration of three days and involve the frequent passage of watery stools,
exceeding a frequency of six times per day. Chronic stomach discomfort described as
unpleasant and characterized by cramping sensations. His temperature reached a high of 100.5
degrees Fahrenheit.
Over-the-counter Bismuth also known as Pepto Bismol will not provide any relief. The patient
recently traveled to Chicago for a conference and admitted to consuming undercooked red meat
during the visit.
REVIEW OF SYSTEMS
General:
Patient claims to be experiencing chills, exhaustion, and trouble sleeping as a result of frequent
restroom trips. denies experiencing night sweats or unintended weight loss or gain.
HEENT/NECK: denies having trouble with vision, no double vision or blurry vision, denies
having trouble seeing in the dark, denies having trouble hearing, denies having pain in the ears,
no sinus problems or a persistent sore throat, and no problems or difficulty with swallowing.
Cardio: Denies chest pain or discomfort, denies palpitation
Respiratory: Denies shortness of breath and wheezing, denies having a cough or cough with
sputum production
Gastrointestinal: Admits to having diarrhea and loose stools with bloody streaks, sore and
crampy abdominal pain with loss of appetite.
Genitourinary: Admits to having increase frequency with urination, denies pain with urination.
Musculoskeletal/Osteopathic: Denies muscle pain, cramps, stiffness, or swelling
Neurologic: Admits to feeling lightheaded. Denies
Integumentary: Not assessed
Psychiatric: Not assessed
Endocrine: Denies changes in temperature intolerance, excessive perspiration, or increased thirst
Hematologic/Lymphatic: Admits to stool with blood streaks, denies bleeding gums or nose
Allergic/Immunologic: No known allergies
PAST MEDICAL HX: occasional abdominal pain with diarrhea
PMH: chickenpox at a young age, has stomachache occasionally, last time was a year ago
Hospitalizations/Surgeries: none
Preventive health: Up to date on immunizations, covid and flu shot. Physical within a year.
Regular dental visits, twice a year for cleaning Dental cleaning twice a year.
Family: Father 68 y/o healthy, elevated B/P controlled, on medication
Mother 67 Y/O healthy, takes calcium and Vit D
Children 8 and 12 healthy
No grandparents history.
REASON FOR
ENCOUNTER:
DIARRHEA FOR 3
DAYS 4Y/O LEAKING
STOOL BIPOLAR
DISORDERS
,
, lOMoAR cPSD| 46020670
Week 5 Ihuman Assessment
History (Subjective Assessment)
Reason for encounter: Diarrhea for 3 days
HPI: Dylan Barton, is a 42-year-old male marketing partner, has been experiencing symptoms
for the past three days, which include the presence of blood in his stool, chills, headache,
tiredness, fever, stomach pain, and a decrease in appetite. The symptoms of explosive diarrhea
persist for a duration of three days and involve the frequent passage of watery stools,
exceeding a frequency of six times per day. Chronic stomach discomfort described as
unpleasant and characterized by cramping sensations. His temperature reached a high of 100.5
degrees Fahrenheit.
Over-the-counter Bismuth also known as Pepto Bismol will not provide any relief. The patient
recently traveled to Chicago for a conference and admitted to consuming undercooked red meat
during the visit.
REVIEW OF SYSTEMS
General:
Patient claims to be experiencing chills, exhaustion, and trouble sleeping as a result of frequent
restroom trips. denies experiencing night sweats or unintended weight loss or gain.
HEENT/NECK: denies having trouble with vision, no double vision or blurry vision, denies
having trouble seeing in the dark, denies having trouble hearing, denies having pain in the ears,
no sinus problems or a persistent sore throat, and no problems or difficulty with swallowing.
Cardio: Denies chest pain or discomfort, denies palpitation
Respiratory: Denies shortness of breath and wheezing, denies having a cough or cough with
sputum production
Gastrointestinal: Admits to having diarrhea and loose stools with bloody streaks, sore and
crampy abdominal pain with loss of appetite.
Genitourinary: Admits to having increase frequency with urination, denies pain with urination.
Musculoskeletal/Osteopathic: Denies muscle pain, cramps, stiffness, or swelling
Neurologic: Admits to feeling lightheaded. Denies
Integumentary: Not assessed
Psychiatric: Not assessed
Endocrine: Denies changes in temperature intolerance, excessive perspiration, or increased thirst
Hematologic/Lymphatic: Admits to stool with blood streaks, denies bleeding gums or nose
Allergic/Immunologic: No known allergies
PAST MEDICAL HX: occasional abdominal pain with diarrhea
PMH: chickenpox at a young age, has stomachache occasionally, last time was a year ago
Hospitalizations/Surgeries: none
Preventive health: Up to date on immunizations, covid and flu shot. Physical within a year.
Regular dental visits, twice a year for cleaning Dental cleaning twice a year.
Family: Father 68 y/o healthy, elevated B/P controlled, on medication
Mother 67 Y/O healthy, takes calcium and Vit D
Children 8 and 12 healthy
No grandparents history.
