6531 Week 7 iHuman Loose Stools

6531 Week 7 iHuman Loose Stools

Reason for encounter

Loose stools

History Questions 

1. How can I help you today?
2. Do you have any other symptoms or concerns we should discuss?
3. Any change in the frequency of your bowel movements?
4. When did your diarrhea start?
5. How severe is your diarrhea?
6. How long does your diarrhea last?
7. Does your diarrhea come and go?
8. Does anything make your diarrhea better or worse?
9. Do you have diarrhea?
10. When did your abdominal pain start?

History of present illness (HPI)

The patient is a 25 year old female presenting for the evaluation of altered bowel habits characterized by intermittent diarrhea and loose stools daily. She reports atleast 5 episodes of diarrhea every month and 2 – 3 loose stools daily. The diarrhea started 3 months ago and lasts about a day. Both symptoms worsen with caffeine intake or too much stress and have a severity of 3/10. She also reports associated abdominal pain that started about 3 months ago, it is generalized with more of a bloated and cramping feeling. The pain is intermittent, aggravated with stress and relieved with bowel movements. She denies feeling sad/depressed, abnormal vaginal bleeding, pain/discomfort with urination, chest pain, greasy /foul smelling stools, stools that are unusually light in color, black/foul-smelling stools, rectal fullness, change in the shape of stools, weight loss, or fevers.

Physical Exam

• Blood pressure
• Pulse
• Respiration
• Temperature
• Inspect skin overall
• Auscultate lungs
• Auscultate heart
• Inspect abdomen
• Auscultate abdomen

ORDER 6531 WEEK 7 IHUMAN LOOSE STOOLS NOW

Case Findings

1. Altered bowel habits; intermittent diarrhea (at least 5 times per month) and 2 loose stools daily
2. Chronicity of symptoms 3 months in duration
3. Generalized abdominal pain and cramping
4. Symptoms relieved by defecation, worsened with recent stress, caffeine, and food intake

Case Problem Statement

The patient is a 25-year old female with no prior PMH who reports intermittent episodes of diarrhea 5 times per month and a2 loose stools daily for 3 months with generalized abdominal pain and cramping, unrelated to specific food intake. There is increased caffeine consumption and life stressors but no concerning psychiatric symptoms. She denies fever, weight loss, melena, steatorrhea, recent travel, known sick contacts, or family history of gastrointestinal disorders. Vitals are within normal limits and physical examination is notable for a mildly distended abdomen with diffuse mild tenderness and hyperactive bowel sounds but no guarding, rebound tenderness, hernias, or masses. Rovsing’s and stool guaiac tests are negative.

Plan Feedback

Pharmacologic Care

• Prescribe loperamide 2-4 mg PO as needed for loose stools once daily 45 minutes before breakfast
• Prescribe dicyclomine 20mg PO every 6 hours as needed for abdominal cramping
• Recommend taking an over-the-counter probiotic daily

Supportive Care

• Encouraged to keep a food diary to help identify possible food triggers
• Recommend soluble, high fiber diet to help bulk stool

Patient Education

• Provided education on new diagnosis, risk factors, treatment, and medication side effects
• Educated on reducing risk factors and limiting caffeine intake
• Instructions provided on avoiding certain foods that can increase GI symptoms like FOODMAPS and gas-producing foods

Follow-up

• Follow-up in 1 month to assess symptoms
• Cognitive behavioral therapy and LGBT community resources offered for support
• Consider future referral to gastroenterology if symptoms not resolving at next appointment

6531 Week 7 iHuman Loose Stools – The patient is a 25-year old female with no prior PMH who reports intermittent episodes of diarrhea 5 times per month and 2 loose stools daily for 3 months, place your order here.