i-Human Case Summary – 1-Year-Old Patient
Patient: 1-year-old child
Sex: [Male/Female – insert if known]
Chief Complaint: [e.g., Cough, Fever, Poor feeding, Rash, Vomiting, Diarrhea, Ear
tugging, etc.]
Duration of Symptoms: [e.g., 2 days, 1 week, etc.]
1. Chief Complaint (CC):
```haskell
Primary Symptoms: Ask the parent (or caregiver) what is their top concern. Some examples include:
,Fever
Cough
Poor feeding
Vomiting
Diarrhea
Rash
Ear tugging
Behavioral change (e.g., lethargy or irritability)
2. History of Present Illness (HPI):
Onset: When did the symptoms start? Was it sudden or gradual?
Example: "How long has the child had the fever or cough?"
Duration: How long has the illness persisted?"
```
Example: "Has the fever lasted 2 days or more?"
Progression: Has the condition gotten better, worse, or remained the same?
Example: "Has the cough gotten worse or is it getting better?"
, Associated Symptoms: Do there occur other symptoms in addition to the chief complaint?
Example: "Has the child become irritable? Any change in feeding or sleep?"
Inquire about: vomiting, diarrhea, rash, lethargy, change in behavior, shortness of breath, or pain.
Exposures: Have there been any exposures to others who are ill, such as family members or daycare?
Example: "Has anyone else in the household been sick, or has the child had contact with other sick
children?"
Triggers/Relievers: Are there any things that seem to make the symptoms worse or better?
Example: "Does the fever get better with any medications like Tylenol? Does the cough worsen when
the child is lying down?"
3. Past Medical History (PMH):
Birth History:
Full-term or preterm birth?
Birth complications (e.g., low birth weight, jaundice, respiratory distress)?
Immunization Status: Is the child up to date on shots?
Check for any missed vaccinations or specific immunization problems.
Ask specifically about the MMR vaccine (measles, mumps, rubella), DTaP, flu, and Hib vaccines if the
problem is infectious.