i human 6 Billy Johnson CASE STUDY
Case
,COMPREHENSIVE i-HUMAN CASE STUDY: BILLY
JOHNSON
PATIENT DEMOGRAPHICS
, • Name: Billy Johnson
• Age: `13 years
• Gender: Male
• Date of Visit: [Current Date]
• Setting: Pediatric Outpatient Clinic
• Informant: Mother (Mrs. Johnson), reliable historian
CHIEF COMPLAINT (CC)
"Sore throat and fever for 1 day."
HISTORY OF PRESENT ILLNESS (HPI)
Billy Johnson is a 6-year-old male brought to clinic by his
mother with acute onset of symptoms beginning
approximately 24 hours prior to visit. Patient developed
fever to 102.5°F (39.2°C) measured axillary, accompanied
by severe sore throat described as bilateral pain worsening
with swallowing. Mother reports decreased oral intake due
to odynophagia - patient refused breakfast and has
minimal fluid intake (few sips of juice). Associated
symptoms include headache, mild abdominal discomfort,
and malaise. No cough, rhinorrhea, vomiting, or diarrhea
reported. No rash observed.
, Positive Exposures: Known contact with cousin diagnosed
with streptococcal pharyngitis 7 days ago, with direct
contact during weekend playdate.
Interventions: Mother administered children's
acetaminophen (dose unspecified) with temporary fever
reduction, but fever recurred this morning.
Illness Impact: Patient is described as "not himself" -
lethargic, fussy, lying on couch (unusual behavior), with
significant decrease in normal activity level.
PAST MEDICAL HISTORY (PMH)
• Prenatal/Birth: Full-term vaginal delivery, no
complications
• Medical Conditions: None
• Surgeries: None
• Hospitalizations: None
• Immunizations: Up to date per age
• Allergies: NKDA
• Medications: Occasional acetaminophen as needed
(last dose: this morning)
• Tonsil Status: Tonsils present, no history of tonsillitis
Case
,COMPREHENSIVE i-HUMAN CASE STUDY: BILLY
JOHNSON
PATIENT DEMOGRAPHICS
, • Name: Billy Johnson
• Age: `13 years
• Gender: Male
• Date of Visit: [Current Date]
• Setting: Pediatric Outpatient Clinic
• Informant: Mother (Mrs. Johnson), reliable historian
CHIEF COMPLAINT (CC)
"Sore throat and fever for 1 day."
HISTORY OF PRESENT ILLNESS (HPI)
Billy Johnson is a 6-year-old male brought to clinic by his
mother with acute onset of symptoms beginning
approximately 24 hours prior to visit. Patient developed
fever to 102.5°F (39.2°C) measured axillary, accompanied
by severe sore throat described as bilateral pain worsening
with swallowing. Mother reports decreased oral intake due
to odynophagia - patient refused breakfast and has
minimal fluid intake (few sips of juice). Associated
symptoms include headache, mild abdominal discomfort,
and malaise. No cough, rhinorrhea, vomiting, or diarrhea
reported. No rash observed.
, Positive Exposures: Known contact with cousin diagnosed
with streptococcal pharyngitis 7 days ago, with direct
contact during weekend playdate.
Interventions: Mother administered children's
acetaminophen (dose unspecified) with temporary fever
reduction, but fever recurred this morning.
Illness Impact: Patient is described as "not himself" -
lethargic, fussy, lying on couch (unusual behavior), with
significant decrease in normal activity level.
PAST MEDICAL HISTORY (PMH)
• Prenatal/Birth: Full-term vaginal delivery, no
complications
• Medical Conditions: None
• Surgeries: None
• Hospitalizations: None
• Immunizations: Up to date per age
• Allergies: NKDA
• Medications: Occasional acetaminophen as needed
(last dose: this morning)
• Tonsil Status: Tonsils present, no history of tonsillitis
