,Here’s a general outline of the history of present illness
(HPI) and relevant background for a 5-year-old patient
presenting with cough and trouble breathing in the
context of an i-Human case study:
History of Present Illness (HPI)
• Chief Complaint: Cough and difficulty breathing
• Onset: Symptoms started X days ago (gradual or
sudden onset)
• Duration: Persistent or episodic
• Character of Cough: Dry or productive (if
productive, describe sputum: color, consistency)
• Severity: Mild, moderate, or severe difficulty
breathing
• Associated Symptoms:
o Fever? (Yes/No, specify temperature)
o Wheezing? (Yes/No)
o Runny nose or nasal congestion?
o Sore throat?
o Chest pain?
o Cyanosis (bluish skin discoloration)?
o Fatigue or decreased activity?
• Alleviating/Aggravating Factors:
, o Any relief with medication (e.g., albuterol,
antihistamines)?
o Worsening with physical activity or lying down?
o Exposure to cold air or allergens (dust, pets,
smoke)?
Past Medical History (PMH)
• History of asthma, pneumonia, or bronchiolitis?
• Previous hospitalizations for respiratory issues?
• Immunization status (especially DTaP, Hib,
Influenza, COVID-19, Pneumococcal vaccine)
• Any known allergies (food, environmental,
medications)?
Family History (FH)
• Family history of asthma, allergies, eczema, or
respiratory illnesses?
• Any close contacts with recent respiratory
infections (flu, RSV, COVID-19, tuberculosis)?
Social History (SH)
(HPI) and relevant background for a 5-year-old patient
presenting with cough and trouble breathing in the
context of an i-Human case study:
History of Present Illness (HPI)
• Chief Complaint: Cough and difficulty breathing
• Onset: Symptoms started X days ago (gradual or
sudden onset)
• Duration: Persistent or episodic
• Character of Cough: Dry or productive (if
productive, describe sputum: color, consistency)
• Severity: Mild, moderate, or severe difficulty
breathing
• Associated Symptoms:
o Fever? (Yes/No, specify temperature)
o Wheezing? (Yes/No)
o Runny nose or nasal congestion?
o Sore throat?
o Chest pain?
o Cyanosis (bluish skin discoloration)?
o Fatigue or decreased activity?
• Alleviating/Aggravating Factors:
, o Any relief with medication (e.g., albuterol,
antihistamines)?
o Worsening with physical activity or lying down?
o Exposure to cold air or allergens (dust, pets,
smoke)?
Past Medical History (PMH)
• History of asthma, pneumonia, or bronchiolitis?
• Previous hospitalizations for respiratory issues?
• Immunization status (especially DTaP, Hib,
Influenza, COVID-19, Pneumococcal vaccine)
• Any known allergies (food, environmental,
medications)?
Family History (FH)
• Family history of asthma, allergies, eczema, or
respiratory illnesses?
• Any close contacts with recent respiratory
infections (flu, RSV, COVID-19, tuberculosis)?
Social History (SH)
