i-Human Pediatric Case Study: Courtney
Graham – 18-Month Old Female with Acute
Vomiting and Diarrhea | Complete
Comprehensive Assessment & Management
Guide | Full HPI, ROS, Physical Examination,
Differential Diagnoses
,I. PATIENT INFORMATION
Data Element Information
Patient Name Courtney Graham
Age 18 months
Sex Female
Date of Birth [Current date minus 18 months]
Encounter Date [Today's date]
Race/Ethnicity Not specified
Primary Language English
Insurance Status Not specified
Source of Information Mother (reliable historian)
II. FULL CLINICAL DIALOGUE (Verbatim Patient Encounter)
Provider: "Good morning. Thank you for bringing Courtney in today.
What brings you to the clinic?"
Mother: "Hi. Courtney has been vomiting and having diarrhea for
the past two days. I'm really worried about her."
, Provider: "I understand. When did the symptoms start exactly?"
Mother: "It started about two days ago. She threw up for the first
time after breakfast."
Provider: "How many times has she vomited in the past 24 hours?"
Mother: "About 3 or 4 times yesterday. She's had a couple times
today too."
Provider: "What does the vomit look like? Is there any blood or
green color?"
Mother: "No, it's just like... food and liquid. No blood. Not green."
Provider: "And the diarrhea? How many episodes?"
Mother: "She's having about 6 to 8 loose, watery stools a day. No
blood that I can see."
Provider: "Has Courtney had any fever?"
Mother: "She felt a little warm this morning. I checked and it was
100.4."
Provider: "How has she been acting? Is she playing normally?"
Mother: "She's really fussy and irritable. She doesn't want to play.
She just wants me to hold her."
Provider: "Is she drinking anything? Eating?"
Mother: "She's barely drinking. Just little sips of water. She won't eat
solid food at all. I tried giving her Pedialyte but she doesn't like it."
Provider: "How many wet diapers has she had in the last 24 hours?"
Graham – 18-Month Old Female with Acute
Vomiting and Diarrhea | Complete
Comprehensive Assessment & Management
Guide | Full HPI, ROS, Physical Examination,
Differential Diagnoses
,I. PATIENT INFORMATION
Data Element Information
Patient Name Courtney Graham
Age 18 months
Sex Female
Date of Birth [Current date minus 18 months]
Encounter Date [Today's date]
Race/Ethnicity Not specified
Primary Language English
Insurance Status Not specified
Source of Information Mother (reliable historian)
II. FULL CLINICAL DIALOGUE (Verbatim Patient Encounter)
Provider: "Good morning. Thank you for bringing Courtney in today.
What brings you to the clinic?"
Mother: "Hi. Courtney has been vomiting and having diarrhea for
the past two days. I'm really worried about her."
, Provider: "I understand. When did the symptoms start exactly?"
Mother: "It started about two days ago. She threw up for the first
time after breakfast."
Provider: "How many times has she vomited in the past 24 hours?"
Mother: "About 3 or 4 times yesterday. She's had a couple times
today too."
Provider: "What does the vomit look like? Is there any blood or
green color?"
Mother: "No, it's just like... food and liquid. No blood. Not green."
Provider: "And the diarrhea? How many episodes?"
Mother: "She's having about 6 to 8 loose, watery stools a day. No
blood that I can see."
Provider: "Has Courtney had any fever?"
Mother: "She felt a little warm this morning. I checked and it was
100.4."
Provider: "How has she been acting? Is she playing normally?"
Mother: "She's really fussy and irritable. She doesn't want to play.
She just wants me to hold her."
Provider: "Is she drinking anything? Eating?"
Mother: "She's barely drinking. Just little sips of water. She won't eat
solid food at all. I tried giving her Pedialyte but she doesn't like it."
Provider: "How many wet diapers has she had in the last 24 hours?"
