,
, Week #7 i-Human Case Study
Patient: 18-month-old child
Reason for Encounter: Vomiting and Diarrhea
Course: Walden University – Class 6541
Chief Complaint:
“He’s been throwing up and has diarrhea.”
History of Present Illness (HPI):
The patient is an 18-month-old previously healthy male
presenting with 1.5 days of vomiting and watery diarrhea. His
mother reports that the vomiting began suddenly and occurred
several times in the first 12 hours, followed by frequent loose,
watery stools. There is no blood or mucus in the stools. The
child has had reduced appetite, decreased oral intake, and
fewer wet diapers than normal today. He appears lethargic and
more irritable than usual. No known sick contacts, but he
attended daycare earlier in the week.
• Onset: 1.5 days ago
• Duration: Ongoing
• Severity: Moderate
• Associated Symptoms: Lethargy, decreased urine output,
poor appetite
• Negative Symptoms: No fever, rash, abdominal
distension, or respiratory symptoms