, i-Human Case Study: Week 7 Comprehensive (Class 6541)
Patient: Leo Martinez
Age: 4 years
Gender: Male
Reason for Encounter: "Diarrhea and stomach pain for 3 days"
SECTION 1: SUBJECTIVE DATA (History of Presenting Illness - HPI)
Source of Information: Patient's mother; reliable historian.
Chief Complaint (CC): "My son, Leo, has had bad diarrhea and a stomach ache for the
last three days."
History of Presenting Illness (HPI) - OLD CARTS Format:
O (Onset): Symptoms began approximately 3 days ago, starting suddenly.
L (Location): The pain is diffuse, located throughout the abdomen, and described as
cramping. The diarrhea is non-bloody.
D (Duration): Persistent for 3 days with no significant periods of relief.
C (Characteristics): The diarrhea is watery, with frequent episodes (6+ times per day).
The mother describes the stool as having a strong, foul odor. The abdominal pain is
crampy and comes and goes.
A (Aggravating Factors): The abdominal cramping seems to worsen before a bowel
movement. Eating has decreased his appetite.
R (Relieving Factors): No significant relieving factors reported. Over-the-counter
bismuth subsalicylate (Pepto-Bismol) was given but provided no relief.
T (Treatment): Tried OTC bismuth subsalicylate without relief. The mother has been
offering clear fluids.
S (Severity): The mother rates the child's overall discomfort as a 7/10. She is concerned
about dehydration.
Associated Symptoms:
Fever: Positive. Mother reports a temperature of 100.5°F (38.1°C) taken at home.
Vomiting: Denies.
Appetite: Decreased.
Energy Level: Decreased; the child is tired and less active than usual.
Blood in Stool: Denies. Mother notes the stool is watery but reports no visible blood.
Sick Contacts: The mother reports that several children in Leo's preschool class were
absent recently with similar symptoms ("a stomach bug").
Patient: Leo Martinez
Age: 4 years
Gender: Male
Reason for Encounter: "Diarrhea and stomach pain for 3 days"
SECTION 1: SUBJECTIVE DATA (History of Presenting Illness - HPI)
Source of Information: Patient's mother; reliable historian.
Chief Complaint (CC): "My son, Leo, has had bad diarrhea and a stomach ache for the
last three days."
History of Presenting Illness (HPI) - OLD CARTS Format:
O (Onset): Symptoms began approximately 3 days ago, starting suddenly.
L (Location): The pain is diffuse, located throughout the abdomen, and described as
cramping. The diarrhea is non-bloody.
D (Duration): Persistent for 3 days with no significant periods of relief.
C (Characteristics): The diarrhea is watery, with frequent episodes (6+ times per day).
The mother describes the stool as having a strong, foul odor. The abdominal pain is
crampy and comes and goes.
A (Aggravating Factors): The abdominal cramping seems to worsen before a bowel
movement. Eating has decreased his appetite.
R (Relieving Factors): No significant relieving factors reported. Over-the-counter
bismuth subsalicylate (Pepto-Bismol) was given but provided no relief.
T (Treatment): Tried OTC bismuth subsalicylate without relief. The mother has been
offering clear fluids.
S (Severity): The mother rates the child's overall discomfort as a 7/10. She is concerned
about dehydration.
Associated Symptoms:
Fever: Positive. Mother reports a temperature of 100.5°F (38.1°C) taken at home.
Vomiting: Denies.
Appetite: Decreased.
Energy Level: Decreased; the child is tired and less active than usual.
Blood in Stool: Denies. Mother notes the stool is watery but reports no visible blood.
Sick Contacts: The mother reports that several children in Leo's preschool class were
absent recently with similar symptoms ("a stomach bug").
