iHuman Comprehensive Case Study
Avery Brook | 10-Year-Old Female
,Case Study Overview
Element Details
Patient Name Avery Brook
Age 10 years old
Gender Female
Chief Complaint "My stomach hurts and I feel tired all the time"
Duration Approximately 6-8 weeks
Setting Outpatient Pediatric Clinic
Accompanied By Mother, Sarah Brook
Section 1: Chief Complaint & History of Present Illness (HPI)
Chief Complaint
Avery Brook is a 10-year-old female who presents to the pediatric clinic with her mother
reporting abdominal pain and fatigue for the past 6-8 weeks.
History of Present Illness (HPI)
HPI Element Avery's Response
Onset Gradual, started approximately 2 months ago
Location Periumbilical (around the belly button), occasionally generalized
, HPI Element Avery's Response
Duration Intermittent, lasting 30 minutes to several hours
Character Dull, cramping; occasionally sharp after eating
Aggravating
Eating large meals, fatty foods, dairy products, physical activity
Factors
Relieving Factors Rest, small frequent meals, lying down with knees bent
Timing Worse after meals; sometimes awakens her from sleep
Severity 4-6/10 on pain scale (0 = no pain, 10 = worst pain)
Associated Fatigue, pallor, dizziness with standing, occasional nausea (no vomiting), headach
Symptoms cold hands and feet
Additional HPI Details
Question Avery's Response
Any changes in bowel habits? Yes, alternating constipation and loose stools
Any blood in stool? Mother reports no visible blood
Any changes in appetite? Decreased appetite; feels full quickly
Any weight changes? Lost approximately 8 pounds in 2 months (unintentional)
Any fever? No
Any rash? No
Any joint pain? Reports occasional knee pain, worse with activity
Avery Brook | 10-Year-Old Female
,Case Study Overview
Element Details
Patient Name Avery Brook
Age 10 years old
Gender Female
Chief Complaint "My stomach hurts and I feel tired all the time"
Duration Approximately 6-8 weeks
Setting Outpatient Pediatric Clinic
Accompanied By Mother, Sarah Brook
Section 1: Chief Complaint & History of Present Illness (HPI)
Chief Complaint
Avery Brook is a 10-year-old female who presents to the pediatric clinic with her mother
reporting abdominal pain and fatigue for the past 6-8 weeks.
History of Present Illness (HPI)
HPI Element Avery's Response
Onset Gradual, started approximately 2 months ago
Location Periumbilical (around the belly button), occasionally generalized
, HPI Element Avery's Response
Duration Intermittent, lasting 30 minutes to several hours
Character Dull, cramping; occasionally sharp after eating
Aggravating
Eating large meals, fatty foods, dairy products, physical activity
Factors
Relieving Factors Rest, small frequent meals, lying down with knees bent
Timing Worse after meals; sometimes awakens her from sleep
Severity 4-6/10 on pain scale (0 = no pain, 10 = worst pain)
Associated Fatigue, pallor, dizziness with standing, occasional nausea (no vomiting), headach
Symptoms cold hands and feet
Additional HPI Details
Question Avery's Response
Any changes in bowel habits? Yes, alternating constipation and loose stools
Any blood in stool? Mother reports no visible blood
Any changes in appetite? Decreased appetite; feels full quickly
Any weight changes? Lost approximately 8 pounds in 2 months (unintentional)
Any fever? No
Any rash? No
Any joint pain? Reports occasional knee pain, worse with activity
