IHUMAN CASE STUDY: MICHAEL MARTINEZ – AN 18-
MONTH-OLD MALE WITH RSV BRONCHIOLITIS
COMPLICATED BY DAYCARE ATTENDANCE AND
SECONDHAND SMOKE EXPOSURE
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Michael Martinez
Age 18 months old
Gender Male
Date of
[Will be specified in case]
Birth
Date of Visit [Current date]
Source Mother (primary historian)
Mother is reliable, concerned, and provides clear history, though uncertain about medica
Reliability
dosing
Allergies No Known Drug Allergies (NKDA) per mother
Reason for Encounter: "He has been coughing and also has fever. He seems to be
getting sicker, so I thought I should have someone look at him."
Chief Complaint: Cough, fever, and difficulty breathing in an 18-month-old male
, PART 2: PAST MEDICAL HISTORY (PMH)
Category Details
Birth History Not specified in available records
Gestational Age at
Not specified
Birth
Birth Weight Not specified
Perinatal
Not specified
Complications
Prior Medical "He has had a couple of colds over the past few months, but they were not qu
Problems as bad as this."
Prior Hospitalizations None
Prior Emergency Visits None
Immunization Status
Up to date status: Not explicitly stated in available information
Flu shot status: Should be asked per iHuman protocols
PART 3: PAST SURGICAL HISTORY (PSH)
, Surgery Details
None No prior surgical history
PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
Unknown dose
Tylenol 2-3 times Mother
(mother uses Fever
(Acetaminophen) per day (OTC)
dropper)
Medication Adherence Issues
Mother cannot remember the exact amount: "I always have to check the box to figure it
out."
Administration difficulty: "He always spits it out, so I don't know how much he is really
getting."
No other OTC or prescription medications
PART 5: FAMILY HISTORY
Relative Details
Father Smokes at home
, Relative Details
Other family history Not specified in available records
PART 6: SOCIAL HISTORY
Factor Details
Living Situation Lives with parents
Daycare Attendance Yes - "I know some kids at his daycare have been sick."
Sick Contacts Documented sick contacts at daycare
Environmental Exposures Secondhand smoke exposure: "Yes, his dad smokes at home."
Pets Not specified
Mold Exposure Not specified
PART 7: HISTORY OF PRESENT ILLNESS (HPI)
Using OLDCARTS Format
Component Finding
Runny nose started 5 days ago; cough started 2 nights ago; difficulty breathing ha
Onset
worsened since cough started
MONTH-OLD MALE WITH RSV BRONCHIOLITIS
COMPLICATED BY DAYCARE ATTENDANCE AND
SECONDHAND SMOKE EXPOSURE
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Michael Martinez
Age 18 months old
Gender Male
Date of
[Will be specified in case]
Birth
Date of Visit [Current date]
Source Mother (primary historian)
Mother is reliable, concerned, and provides clear history, though uncertain about medica
Reliability
dosing
Allergies No Known Drug Allergies (NKDA) per mother
Reason for Encounter: "He has been coughing and also has fever. He seems to be
getting sicker, so I thought I should have someone look at him."
Chief Complaint: Cough, fever, and difficulty breathing in an 18-month-old male
, PART 2: PAST MEDICAL HISTORY (PMH)
Category Details
Birth History Not specified in available records
Gestational Age at
Not specified
Birth
Birth Weight Not specified
Perinatal
Not specified
Complications
Prior Medical "He has had a couple of colds over the past few months, but they were not qu
Problems as bad as this."
Prior Hospitalizations None
Prior Emergency Visits None
Immunization Status
Up to date status: Not explicitly stated in available information
Flu shot status: Should be asked per iHuman protocols
PART 3: PAST SURGICAL HISTORY (PSH)
, Surgery Details
None No prior surgical history
PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
Unknown dose
Tylenol 2-3 times Mother
(mother uses Fever
(Acetaminophen) per day (OTC)
dropper)
Medication Adherence Issues
Mother cannot remember the exact amount: "I always have to check the box to figure it
out."
Administration difficulty: "He always spits it out, so I don't know how much he is really
getting."
No other OTC or prescription medications
PART 5: FAMILY HISTORY
Relative Details
Father Smokes at home
, Relative Details
Other family history Not specified in available records
PART 6: SOCIAL HISTORY
Factor Details
Living Situation Lives with parents
Daycare Attendance Yes - "I know some kids at his daycare have been sick."
Sick Contacts Documented sick contacts at daycare
Environmental Exposures Secondhand smoke exposure: "Yes, his dad smokes at home."
Pets Not specified
Mold Exposure Not specified
PART 7: HISTORY OF PRESENT ILLNESS (HPI)
Using OLDCARTS Format
Component Finding
Runny nose started 5 days ago; cough started 2 nights ago; difficulty breathing ha
Onset
worsened since cough started
