i-Human Javier Flores – Complete 31-Page Case
Walkthrough: 18-Month-Old with RSV Bronchiolitis (Cough,
Wheezing, Retractions) – Latest 2026/2027
SECTION 1: CASE SETUP & INITIAL DATA
OVERVIEW
Parameter Details
Patient Javier Flores
Age 18 months
, Height 2'10" (86 cm)
Weight 28.0 lb (12.7 kg)
Reason for Encounter Cough
Setting Outpatient pediatric clinic
Accompanied by Primary caregiver (mother)
Mode Test Mode – No feedback after submission
SECTION 2: CHIEF COMPLAINT & HISTORY OF PRESENT ILLNESS
CHIEF COMPLAINT
Parent states: "He's been coughing a lot, not eating well, and breathing seems faster."
Documentation:
CC: "He's been coughing a lot, not eating well, and breathing seems faster."
HISTORY OF PRESENT ILLNESS (HPI) – OLDCARTS FORMAT
Component Findings
Onset Cough began approximately 3-4 days ago; gradual worsening over the past 2 days
Location Chest/throat area; described as "coming from the chest"
Duration 4 days since onset of cough
Characteristics Cough is described as "barky" and worse at night. Parent reports "wheezing" sound at
times. Cough is productive? (Unknown). No history of choking.
Aggravating Worse at night, worse when lying flat, worse with crying or agitation
Factors
Relieving Factors "Sitting up" helps; cool mist vaporizer has been used with some relief
Timing Worse at night; present throughout the day but less frequent when active
Severity Cough is "keeping him up at night" and "affecting his eating"
Associated Rhinorrhea (clear discharge), fever (100.5°F at home), decreased appetite, increased
Symptoms work of breathing, decreased activity level
SECTION 3: REVIEW OF SYSTEMS (ROS)
,GENERAL
Symptom Present? Details
Fever Yes 100.5°F at home, felt warm to touch
Chills Unknown Unable to assess reliably
Fatigue/Lethargy Yes "Not himself, less playful"
Activity Level Decreased More sleepy, less interactive
Weight Loss Unknown Not reported
HEAD, EYES, EARS, NOSE, THROAT (HEENT)
Symptom Present? Details
Headache Unknown Unable to verbalize
Nasal Discharge Yes Clear rhinorrhea
Nasal Congestion Yes "Stuffy nose, trouble breathing through nose"
Sneezing Yes Occasional sneezing
Sore Throat Unknown Unable to verbalize
Eye Discharge No None reported
Ear Pain Unknown Unable to verbalize; no ear tugging reported
Red Eyes No None reported
RESPIRATORY
Symptom Present? Details
Cough Yes Barky cough, worse at night
Wheezing Yes "Wheezing sound" reported by parent
Shortness of Breath Yes "Breathing seems faster"
Retractions Yes Parent reports "sucking in" between ribs
Nasal Flaring Yes Reported by parent
Grunting Unknown Not reported
Cyanosis No None reported
, Sputum Unknown Unable to expectorate
CARDIOVASCULAR
Symptom Present? Details
Cyanosis No None reported
Chest Pain Unknown Unable to verbalize
Palpitations Unknown Unable to assess
Edema No None reported
GASTROINTESTINAL
Symptom Present? Details
Appetite Decreased "Not eating well"
Nausea/Vomiting Yes Vomited once after coughing episode
Diarrhea No None reported
Constipation Unknown Not reported
Abdominal Pain Unknown Unable to verbalize
Hydration Unknown Wet diapers? Parent reports "fewer wet diapers"
DERMATOLOGICAL
Symptom Present? Details
Rash No None reported
Skin Color Normal No pallor or cyanosis reported
Diaper Rash No None reported
NEUROLOGICAL
Symptom Present? Details
Irritability Yes "More fussy than usual"
Lethargy Yes "Sleeping more, harder to wake"
Walkthrough: 18-Month-Old with RSV Bronchiolitis (Cough,
Wheezing, Retractions) – Latest 2026/2027
SECTION 1: CASE SETUP & INITIAL DATA
OVERVIEW
Parameter Details
Patient Javier Flores
Age 18 months
, Height 2'10" (86 cm)
Weight 28.0 lb (12.7 kg)
Reason for Encounter Cough
Setting Outpatient pediatric clinic
Accompanied by Primary caregiver (mother)
Mode Test Mode – No feedback after submission
SECTION 2: CHIEF COMPLAINT & HISTORY OF PRESENT ILLNESS
CHIEF COMPLAINT
Parent states: "He's been coughing a lot, not eating well, and breathing seems faster."
Documentation:
CC: "He's been coughing a lot, not eating well, and breathing seems faster."
HISTORY OF PRESENT ILLNESS (HPI) – OLDCARTS FORMAT
Component Findings
Onset Cough began approximately 3-4 days ago; gradual worsening over the past 2 days
Location Chest/throat area; described as "coming from the chest"
Duration 4 days since onset of cough
Characteristics Cough is described as "barky" and worse at night. Parent reports "wheezing" sound at
times. Cough is productive? (Unknown). No history of choking.
Aggravating Worse at night, worse when lying flat, worse with crying or agitation
Factors
Relieving Factors "Sitting up" helps; cool mist vaporizer has been used with some relief
Timing Worse at night; present throughout the day but less frequent when active
Severity Cough is "keeping him up at night" and "affecting his eating"
Associated Rhinorrhea (clear discharge), fever (100.5°F at home), decreased appetite, increased
Symptoms work of breathing, decreased activity level
SECTION 3: REVIEW OF SYSTEMS (ROS)
,GENERAL
Symptom Present? Details
Fever Yes 100.5°F at home, felt warm to touch
Chills Unknown Unable to assess reliably
Fatigue/Lethargy Yes "Not himself, less playful"
Activity Level Decreased More sleepy, less interactive
Weight Loss Unknown Not reported
HEAD, EYES, EARS, NOSE, THROAT (HEENT)
Symptom Present? Details
Headache Unknown Unable to verbalize
Nasal Discharge Yes Clear rhinorrhea
Nasal Congestion Yes "Stuffy nose, trouble breathing through nose"
Sneezing Yes Occasional sneezing
Sore Throat Unknown Unable to verbalize
Eye Discharge No None reported
Ear Pain Unknown Unable to verbalize; no ear tugging reported
Red Eyes No None reported
RESPIRATORY
Symptom Present? Details
Cough Yes Barky cough, worse at night
Wheezing Yes "Wheezing sound" reported by parent
Shortness of Breath Yes "Breathing seems faster"
Retractions Yes Parent reports "sucking in" between ribs
Nasal Flaring Yes Reported by parent
Grunting Unknown Not reported
Cyanosis No None reported
, Sputum Unknown Unable to expectorate
CARDIOVASCULAR
Symptom Present? Details
Cyanosis No None reported
Chest Pain Unknown Unable to verbalize
Palpitations Unknown Unable to assess
Edema No None reported
GASTROINTESTINAL
Symptom Present? Details
Appetite Decreased "Not eating well"
Nausea/Vomiting Yes Vomited once after coughing episode
Diarrhea No None reported
Constipation Unknown Not reported
Abdominal Pain Unknown Unable to verbalize
Hydration Unknown Wet diapers? Parent reports "fewer wet diapers"
DERMATOLOGICAL
Symptom Present? Details
Rash No None reported
Skin Color Normal No pallor or cyanosis reported
Diaper Rash No None reported
NEUROLOGICAL
Symptom Present? Details
Irritability Yes "More fussy than usual"
Lethargy Yes "Sleeping more, harder to wake"
