Comprehensive iHuman Week 7 Case Study: 25-Year-Old
Female with Chronic Loose Stools (IBS-D) – Detailed Clinical
Analysis and SOAP Documenta on
Pa ent Profile
Age: 25 years
Sex: Female
Se ng: Primary care clinic
Source of History: Pa ent (reliable historian)
, Chief Complaint (CC)
"I’ve been having frequent loose stools for the past few weeks."
History of Present Illness (HPI)
The pa ent is a 25-year-old female who presents with a 3-week history of loose stools occurring
3–5 mes per day. She describes the stools as watery to loose, brown in color, and non-bloody.
Symptoms began gradually and have persisted without significant improvement.
She reports mild, intermi ent lower abdominal cramping that improves a er bowel
movements. She also notes urgency but denies fecal incon nence. There is no associated fever,
chills, nausea, or vomi ng. She denies nocturnal diarrhea.
The pa ent reports increased stress at work and recent dietary changes, including increased
caffeine intake and frequent fast-food consump on. She denies recent travel, an bio c use, or
exposure to sick contacts. No similar symptoms in household members.
She reports adequate hydra on but decreased appe te. No uninten onal weight loss is
reported.
Past Medical History (PMH)
Irritable bowel symptoms (self-reported, not formally diagnosed)
No chronic medical condi ons
Surgical History
None
Medica ons
Oral contracep ve pill
Occasional ibuprofen
Female with Chronic Loose Stools (IBS-D) – Detailed Clinical
Analysis and SOAP Documenta on
Pa ent Profile
Age: 25 years
Sex: Female
Se ng: Primary care clinic
Source of History: Pa ent (reliable historian)
, Chief Complaint (CC)
"I’ve been having frequent loose stools for the past few weeks."
History of Present Illness (HPI)
The pa ent is a 25-year-old female who presents with a 3-week history of loose stools occurring
3–5 mes per day. She describes the stools as watery to loose, brown in color, and non-bloody.
Symptoms began gradually and have persisted without significant improvement.
She reports mild, intermi ent lower abdominal cramping that improves a er bowel
movements. She also notes urgency but denies fecal incon nence. There is no associated fever,
chills, nausea, or vomi ng. She denies nocturnal diarrhea.
The pa ent reports increased stress at work and recent dietary changes, including increased
caffeine intake and frequent fast-food consump on. She denies recent travel, an bio c use, or
exposure to sick contacts. No similar symptoms in household members.
She reports adequate hydra on but decreased appe te. No uninten onal weight loss is
reported.
Past Medical History (PMH)
Irritable bowel symptoms (self-reported, not formally diagnosed)
No chronic medical condi ons
Surgical History
None
Medica ons
Oral contracep ve pill
Occasional ibuprofen
