Pediatric Clinical Decision-Making: Evaluating Cough in
an 18-Month-Old Patient
Pediatric Case Study: 18-Month-Old Male with Acute Viral
Gastroenteritis
1. Patient Demographics & Identifying Data
Patient Initials: J.F. (Javier Flores)
Age: 18 months
Gender: Male
Ethnicity: Hispanic/Latino
Height: 2 ft 10 in (86 cm)
Weight: 28 lb (12.7 kg)
Occupation: Not applicable (toddler)
,Living Situation (Social History): Lives with both parents and an
older brother in a smoke-free home. Attends daycare five days
per week. Several children at daycare recently experienced
vomiting and diarrhea.
Source of Information: Mother, who is considered a reliable
historian.
2. Chief Complaint (CC)
"My son has been vomiting and having diarrhea since
yesterday."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 24 hours ago with sudden-onset vomiting
followed several hours later by watery diarrhea.
Location
Generalized abdominal discomfort without localized pain.
Duration
Vomiting has occurred six times over the past 24 hours.
Diarrhea has occurred approximately eight times.
Characteristics
, Mother reports non-bloody, non-bilious vomiting and frequent
watery diarrhea. The child appears more tired than usual and
has refused most solid foods but is taking small amounts of oral
fluids.
Aggravating Factors
• Eating solid foods
• Drinking large amounts of fluid quickly
• Physical activity
Relieving Factors
• Small frequent sips of oral rehydration solution
• Rest
• Sitting upright after drinking
Treatment
Mother has provided:
• Oral rehydration solution (Pedialyte®)
• Small frequent sips of water
• Bland foods as tolerated
No over-the-counter antidiarrheal medications have been given.
Severity
an 18-Month-Old Patient
Pediatric Case Study: 18-Month-Old Male with Acute Viral
Gastroenteritis
1. Patient Demographics & Identifying Data
Patient Initials: J.F. (Javier Flores)
Age: 18 months
Gender: Male
Ethnicity: Hispanic/Latino
Height: 2 ft 10 in (86 cm)
Weight: 28 lb (12.7 kg)
Occupation: Not applicable (toddler)
,Living Situation (Social History): Lives with both parents and an
older brother in a smoke-free home. Attends daycare five days
per week. Several children at daycare recently experienced
vomiting and diarrhea.
Source of Information: Mother, who is considered a reliable
historian.
2. Chief Complaint (CC)
"My son has been vomiting and having diarrhea since
yesterday."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 24 hours ago with sudden-onset vomiting
followed several hours later by watery diarrhea.
Location
Generalized abdominal discomfort without localized pain.
Duration
Vomiting has occurred six times over the past 24 hours.
Diarrhea has occurred approximately eight times.
Characteristics
, Mother reports non-bloody, non-bilious vomiting and frequent
watery diarrhea. The child appears more tired than usual and
has refused most solid foods but is taking small amounts of oral
fluids.
Aggravating Factors
• Eating solid foods
• Drinking large amounts of fluid quickly
• Physical activity
Relieving Factors
• Small frequent sips of oral rehydration solution
• Rest
• Sitting upright after drinking
Treatment
Mother has provided:
• Oral rehydration solution (Pedialyte®)
• Small frequent sips of water
• Bland foods as tolerated
No over-the-counter antidiarrheal medications have been given.
Severity
