I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
,I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
PATIENT PROFILE
Age: 28 years
Sex: Female
Occupation: Office administrator
Marital status: Single
Residence: Urban setting
Presenting Complaint
Loose stools for 6 days
History of Present Illness
The patient reports that her symptoms began suddenly 6 days ago. She passes watery,
non-bloody stools approximately 4-6 times daily. She describes mild abdominal
cramping that improves after defecation. There is no vomiting, but she reports mild
nausea.
HPI Questions (Doctor-Patient Interview)
Doctor: “How may I help you today?”
Patient: “I’ve been having loose stools for almost a week now.”
,I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
Doctor: “When did the problem start?”
Patient: “It started about six days ago, quite suddenly.”
Doctor: “How many times do you pass stool in a day?”
Patient: “Around four to six times a day.”
Doctor: “How would you describe the stool?”
Patient: “It’s watery and not well formed.”
Doctor: “Have you noticed any blood or mucus in your stool?”
Patient: “No, there’s no blood or mucus.”
Doctor: “Do you feel any abdominal pain?”
Patient: “I get mild cramps that improve after I go to the toilet.”
Doctor: “Have you had a fever or chills?”
Patient: “No, I haven’t had any fever or chills.”
Doctor: “Any nausea or vomiting?”
Patient: “I feel a little nauseated sometimes, but I haven’t vomited.”
Doctor: “Do the symptoms wake you up at night?”
Patient: “No, I don’t wake up to use the bathroom.”
Doctor: “Have you noticed any weight loss?”
Patient: “No, my weight hasn’t changed.”
, I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
Doctor: “Does anything make the symptoms better or worse?”
Patient: “The cramps get better after passing stool, but eating can make it worse.”
Doctor: “Did you eat anything unusual before this started?”
Patient: “Yes, I ate street food at a social event the day before.”
Doctor: “Has anyone close to you had similar symptoms?”
Patient: “No, no one else seems sick.”
Doctor: “Have you traveled recently?”
Patient: “No, I haven’t traveled recently.”
Doctor: “Have you used any antibiotics recently?”
Patient: “No, I haven’t taken antibiotics.”
Doctor: “Do you have any long-term medical conditions?”
Patient: “No, I’m generally healthy.”
Doctor: “Are you taking any medications or supplements?”
Patient: “No, I’m not taking anything regularly.”
Doctor: “Have you felt dizzy or noticed a dry mouth?”
Patient: “My mouth feels a bit dry, but I haven’t felt dizzy.”
Doctor: “How much fluid are you drinking?”
Patient: “Probably less than usual, but I try to drink water.”
Female with Loose Stool (Week #7)
,I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
PATIENT PROFILE
Age: 28 years
Sex: Female
Occupation: Office administrator
Marital status: Single
Residence: Urban setting
Presenting Complaint
Loose stools for 6 days
History of Present Illness
The patient reports that her symptoms began suddenly 6 days ago. She passes watery,
non-bloody stools approximately 4-6 times daily. She describes mild abdominal
cramping that improves after defecation. There is no vomiting, but she reports mild
nausea.
HPI Questions (Doctor-Patient Interview)
Doctor: “How may I help you today?”
Patient: “I’ve been having loose stools for almost a week now.”
,I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
Doctor: “When did the problem start?”
Patient: “It started about six days ago, quite suddenly.”
Doctor: “How many times do you pass stool in a day?”
Patient: “Around four to six times a day.”
Doctor: “How would you describe the stool?”
Patient: “It’s watery and not well formed.”
Doctor: “Have you noticed any blood or mucus in your stool?”
Patient: “No, there’s no blood or mucus.”
Doctor: “Do you feel any abdominal pain?”
Patient: “I get mild cramps that improve after I go to the toilet.”
Doctor: “Have you had a fever or chills?”
Patient: “No, I haven’t had any fever or chills.”
Doctor: “Any nausea or vomiting?”
Patient: “I feel a little nauseated sometimes, but I haven’t vomited.”
Doctor: “Do the symptoms wake you up at night?”
Patient: “No, I don’t wake up to use the bathroom.”
Doctor: “Have you noticed any weight loss?”
Patient: “No, my weight hasn’t changed.”
, I-Human Case Study Examining 28-Year Old
Female with Loose Stool (Week #7)
Doctor: “Does anything make the symptoms better or worse?”
Patient: “The cramps get better after passing stool, but eating can make it worse.”
Doctor: “Did you eat anything unusual before this started?”
Patient: “Yes, I ate street food at a social event the day before.”
Doctor: “Has anyone close to you had similar symptoms?”
Patient: “No, no one else seems sick.”
Doctor: “Have you traveled recently?”
Patient: “No, I haven’t traveled recently.”
Doctor: “Have you used any antibiotics recently?”
Patient: “No, I haven’t taken antibiotics.”
Doctor: “Do you have any long-term medical conditions?”
Patient: “No, I’m generally healthy.”
Doctor: “Are you taking any medications or supplements?”
Patient: “No, I’m not taking anything regularly.”
Doctor: “Have you felt dizzy or noticed a dry mouth?”
Patient: “My mouth feels a bit dry, but I haven’t felt dizzy.”
Doctor: “How much fluid are you drinking?”
Patient: “Probably less than usual, but I try to drink water.”
