iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
Patient Information: SG, 18-month-old, African-American, Female
Subjective:
CC (chief complaint): Vomiting and diarrhea
HPI: Samantha is a 18-month-old female who presents today with her mother with complaints of
vomiting and diarrhea times 2 days. Sister recently had similar symptoms. Her mother reports
that Samantha has vomited 4-5 times daily for the past two days and had 3-4 episodes of liquid
diarrhea daily for the past two days. Vomit is liquid with some partially digested food. Diarrhea
is liquid. Denies coffee-ground emesis or blood in stool or vomit. No fever, cough, decreased
activity. The mother does report concerns over decreased appetite. Had been taking Pedialyte
and tolerating small amounts of Pedialyte and milk. Physical exam without signs of dehydration,
abdominal pain, or rebound tenderness.
Current meds: None
Allergies: NKDA
Pertinent PMHx: Samantha is in general good health. No pertinent past medical history noted.
She is up to date on immunizations and has regular check-ups. She has met all developmental
milestones for her age and is at the 75th percentile for height and weight.
Immunizations:
Birth: Hep B
2 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B
4 months: DTaP, IPV, HIB, PCV13, Rotavirus,
6 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza 1st dose
7 months: Influenza 2nd dose
12 months: MMR, Varicella, Hep A 1st dose
15 months: DTaP, HIB, PCV13, due today
iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
, iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
Social hx: Lives in an apartment with her parents and 4 year old sister. Her mother is a teacher
and her father is an engineer.
Fam Hx:
1. Mother, 32-years-old, healthy
2. Father, 36-years-old, healthy
History Questions Asked:
1. How can I help her today?
2. When did her nausea and/or vomiting start?
3. What are the events surrounding the start of her nausea and/or vomiting?
4. Does anything make her nausea and/or vomiting better or worse?
5. Does she have any pain or other symptoms associated with her nausea and/or
vomiting?
6. How severe is her nausea and/or vomiting?
7. Has she vomited so forcefully that the vomit went to the other side of the room?
8. Do you have any pain in your abdomen?
9. Does she have diarrhea?
10. Does she have bloody stools?
11. Does she have black tar-like or foul smelling stools?
12. When did her diarrhea start?
13. Do her symptoms persist if she stops eating?
14. Does she have any pain or other symptoms associated with her diarrhea?
15. Does her diarrhea keep her from sleeping?
16. Has she had diarrhea like this before?
iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
Patient Information: SG, 18-month-old, African-American, Female
Subjective:
CC (chief complaint): Vomiting and diarrhea
HPI: Samantha is a 18-month-old female who presents today with her mother with complaints of
vomiting and diarrhea times 2 days. Sister recently had similar symptoms. Her mother reports
that Samantha has vomited 4-5 times daily for the past two days and had 3-4 episodes of liquid
diarrhea daily for the past two days. Vomit is liquid with some partially digested food. Diarrhea
is liquid. Denies coffee-ground emesis or blood in stool or vomit. No fever, cough, decreased
activity. The mother does report concerns over decreased appetite. Had been taking Pedialyte
and tolerating small amounts of Pedialyte and milk. Physical exam without signs of dehydration,
abdominal pain, or rebound tenderness.
Current meds: None
Allergies: NKDA
Pertinent PMHx: Samantha is in general good health. No pertinent past medical history noted.
She is up to date on immunizations and has regular check-ups. She has met all developmental
milestones for her age and is at the 75th percentile for height and weight.
Immunizations:
Birth: Hep B
2 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B
4 months: DTaP, IPV, HIB, PCV13, Rotavirus,
6 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza 1st dose
7 months: Influenza 2nd dose
12 months: MMR, Varicella, Hep A 1st dose
15 months: DTaP, HIB, PCV13, due today
iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
, iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
Social hx: Lives in an apartment with her parents and 4 year old sister. Her mother is a teacher
and her father is an engineer.
Fam Hx:
1. Mother, 32-years-old, healthy
2. Father, 36-years-old, healthy
History Questions Asked:
1. How can I help her today?
2. When did her nausea and/or vomiting start?
3. What are the events surrounding the start of her nausea and/or vomiting?
4. Does anything make her nausea and/or vomiting better or worse?
5. Does she have any pain or other symptoms associated with her nausea and/or
vomiting?
6. How severe is her nausea and/or vomiting?
7. Has she vomited so forcefully that the vomit went to the other side of the room?
8. Do you have any pain in your abdomen?
9. Does she have diarrhea?
10. Does she have bloody stools?
11. Does she have black tar-like or foul smelling stools?
12. When did her diarrhea start?
13. Do her symptoms persist if she stops eating?
14. Does she have any pain or other symptoms associated with her diarrhea?
15. Does her diarrhea keep her from sleeping?
16. Has she had diarrhea like this before?
iHuman Case Study Stomach Upset & Vomiting in 18-Month-Old
