I HUMAN CASE WEEK 7 COMPREHENSIVE PRIMARY CARE
ASSESSMENT AND EVIDENCE BASED MANAGEMENT OF A 25 YEAR
OLD FEMALE PRESENTING WITH CHRONIC LOOSE STOOLS
ABDOMINAL CRAMPING, DIETARY AND PSYCHOSOCIAL TRIGGERS,
AND FUNCTIONAL IMPAIRMENT IN AN OUTPATIENT CLINICAL
SETTING
,PATIENT INFORMATION
Age: 25 years
Gender: Female
Height: 5′4″ (163 cm)
Weight: 128 lb (58.2 kg)
BMI: 22.0 kg/m²
Clinical Setting: Outpatient primary care clinic with laboratory and diagnostic services
Reason for Visit: Persistent loose stools
The patient is a 25-year-old woman with a normal body mass index, indicating normal nutritional
status. She is emotionally stable but reports moderate stress related to academic and work
demands. She presents to an outpatient primary care clinic capable of performing laboratory
assessments. The patient is cognitively intact, able to provide reliable symptom history, and
motivated for diagnostic clarity and treatment.
, REASON FOR ENCOUNTER
Clinical Aspect Patient-Reported Detail
Primary Concern Loose stools with abdominal symptoms
Onset Gradual over ~3 months
Frequency 4–6 bowel movements/day
Stool Description Loose, fluffy, non-bloody, non-mucous
Associated Symptoms Mild lower abdominal cramping, bloating
Aggravating Factors Caffeine intake, stress
Relieving Factors Partial relief after bowel movement
Impact on Life Disruption of daily activities, social anxiety
This 25-year-old female presents for evaluation of persistent loose stools that have been occurring
for approximately three months. She reports frequent loose, watery bowel movements with
associated lower abdominal cramping and bloating. Symptoms occur daily and are worsened by
frequent caffeine intake and emotional stress. She denies fever, chills, weight loss, rectal bleeding,
nocturnal diarrhea, or recent antibiotic use. She reports partial relief after bowel movements but
notes that her quality of life and academic performance have declined due to unpredictability of
symptoms. The patient seeks diagnostic clarification, exclusion of serious pathology, and a tailored
evidence-based management plan.
ASSESSMENT AND EVIDENCE BASED MANAGEMENT OF A 25 YEAR
OLD FEMALE PRESENTING WITH CHRONIC LOOSE STOOLS
ABDOMINAL CRAMPING, DIETARY AND PSYCHOSOCIAL TRIGGERS,
AND FUNCTIONAL IMPAIRMENT IN AN OUTPATIENT CLINICAL
SETTING
,PATIENT INFORMATION
Age: 25 years
Gender: Female
Height: 5′4″ (163 cm)
Weight: 128 lb (58.2 kg)
BMI: 22.0 kg/m²
Clinical Setting: Outpatient primary care clinic with laboratory and diagnostic services
Reason for Visit: Persistent loose stools
The patient is a 25-year-old woman with a normal body mass index, indicating normal nutritional
status. She is emotionally stable but reports moderate stress related to academic and work
demands. She presents to an outpatient primary care clinic capable of performing laboratory
assessments. The patient is cognitively intact, able to provide reliable symptom history, and
motivated for diagnostic clarity and treatment.
, REASON FOR ENCOUNTER
Clinical Aspect Patient-Reported Detail
Primary Concern Loose stools with abdominal symptoms
Onset Gradual over ~3 months
Frequency 4–6 bowel movements/day
Stool Description Loose, fluffy, non-bloody, non-mucous
Associated Symptoms Mild lower abdominal cramping, bloating
Aggravating Factors Caffeine intake, stress
Relieving Factors Partial relief after bowel movement
Impact on Life Disruption of daily activities, social anxiety
This 25-year-old female presents for evaluation of persistent loose stools that have been occurring
for approximately three months. She reports frequent loose, watery bowel movements with
associated lower abdominal cramping and bloating. Symptoms occur daily and are worsened by
frequent caffeine intake and emotional stress. She denies fever, chills, weight loss, rectal bleeding,
nocturnal diarrhea, or recent antibiotic use. She reports partial relief after bowel movements but
notes that her quality of life and academic performance have declined due to unpredictability of
symptoms. The patient seeks diagnostic clarification, exclusion of serious pathology, and a tailored
evidence-based management plan.
