Comprehensive Case Study ;18 month old patient reason
for encounter:vomiting and diarrhea (6541) iHuman
Case Analysis Week #7 latest 2024
,Chief Complaint:
Primary Concern: Vomiting and diarrhea for the past 2 days.
Reported by: The child’s mother.
History of Present Illness (HPI):
Duration: 2 days of symptoms.
Vomiting:
o The child has vomited 4-5 times per day over the past two days.
o The vomit is clear or contains food particles. There is no blood or bile.
Diarrhea:
o The child has experienced frequent, watery stools in the last 48 hours.
o There is no blood or mucus in the stool.
Oral Intake:
o The child is refusing solid foods but can drink small sips of water and fluids.
Urine Output:
o The child’s urine output has decreased slightly, which may indicate mild
dehydration, but the child is still urinating.
Fever:
o The child does not have a fever.
Sick Contacts:
o The child’s sister recently had similar symptoms of vomiting and diarrhea.
Dietary Changes:
, o There have been no recent dietary changes or introduction of new foods.
Energy Levels:
o The child is less active than usual and irritable, but not lethargic or excessively
sleepy.
Travel History:
o There has been no recent travel.
Vaccination Status:
o The child is up-to-date on vaccinations, including the rotavirus vaccine.
Direct History and Physical Questions (HPQ) with Answers:
1. Is the child vomiting?
o Yes, the child is vomiting 4-5 times per day.
2. What does the vomit look like?
o The vomit is clear or has small food particles. There is no blood or bile.
3. Is the child having diarrhea?
o Yes, the child has had frequent, watery stools.
4. Is there blood or mucus in the stool?
o No, the stool is watery, with no blood or mucus.
5. Does the child have a fever?
o No, the child does not have a fever.
6. How is the child’s oral intake?
o The child is refusing solid food but is drinking small amounts of water and
fluids.
for encounter:vomiting and diarrhea (6541) iHuman
Case Analysis Week #7 latest 2024
,Chief Complaint:
Primary Concern: Vomiting and diarrhea for the past 2 days.
Reported by: The child’s mother.
History of Present Illness (HPI):
Duration: 2 days of symptoms.
Vomiting:
o The child has vomited 4-5 times per day over the past two days.
o The vomit is clear or contains food particles. There is no blood or bile.
Diarrhea:
o The child has experienced frequent, watery stools in the last 48 hours.
o There is no blood or mucus in the stool.
Oral Intake:
o The child is refusing solid foods but can drink small sips of water and fluids.
Urine Output:
o The child’s urine output has decreased slightly, which may indicate mild
dehydration, but the child is still urinating.
Fever:
o The child does not have a fever.
Sick Contacts:
o The child’s sister recently had similar symptoms of vomiting and diarrhea.
Dietary Changes:
, o There have been no recent dietary changes or introduction of new foods.
Energy Levels:
o The child is less active than usual and irritable, but not lethargic or excessively
sleepy.
Travel History:
o There has been no recent travel.
Vaccination Status:
o The child is up-to-date on vaccinations, including the rotavirus vaccine.
Direct History and Physical Questions (HPQ) with Answers:
1. Is the child vomiting?
o Yes, the child is vomiting 4-5 times per day.
2. What does the vomit look like?
o The vomit is clear or has small food particles. There is no blood or bile.
3. Is the child having diarrhea?
o Yes, the child has had frequent, watery stools.
4. Is there blood or mucus in the stool?
o No, the stool is watery, with no blood or mucus.
5. Does the child have a fever?
o No, the child does not have a fever.
6. How is the child’s oral intake?
o The child is refusing solid food but is drinking small amounts of water and
fluids.
