18-Month-Old Patient with Vomiting and
Diarrhea iHuman Case Study | Comprehensive
Case Study Analysis with All Sections week#- 7
,1. History of Present Illness (HPI)
An 18-month-old male is brought to the clinic by his mother due to vomiting and diarrhea for
the past 36 hours.
The vomiting began suddenly, initially with partially digested food and later became watery and
non-bilious. The child has vomited 4–5 times in the last 24 hours. Diarrhea began about 6 hours
after the onset of vomiting, described as watery, yellowish, non-bloody, occurring about 6
times per day.
Mother reports the child has been less active, irritable, and refuses solid foods, but drinks small
amounts of water and breast milk. She noticed fewer wet diapers (only 2 since morning). No
blood in stool, no recent antibiotic use, and no known food allergies. No travel or exposure to
untreated water.
There was a recent daycare outbreak of “stomach flu” in two other children.
, Associated symptoms: Mild fever (up to 38.5°C), no cough, no rash, no ear pulling, no
abdominal distension.
Aggravating factors: Eating solids or milk.
Relieving factors: None noted.
Treatment tried: Oral rehydration solution (ORS) once; vomiting followed.
2. Past Medical History
• Birth history: Full-term, normal vaginal delivery.
• Growth and development: Age-appropriate milestones.
• Past illnesses: Mild upper respiratory infections, no hospitalizations.
• Medications: None.
• Allergies: None known (NKDA).
• Immunizations: Up to date, including rotavirus vaccine.
3. Family and Social History
• Lives with parents and older sibling (4 years old, recently had mild diarrhea).
• Attends daycare 3 days per week.
• No family history of gastrointestinal disease or immune deficiency.
• No exposure to animals or recent travel.
4. Review of Systems (ROS)
System Findings
General Fever, irritability, decreased appetite, tiredness
HEENT No ear pain, no nasal congestion
Cardiac No cyanosis, no murmurs reported
Respiratory No cough, no difficulty breathing
GI Vomiting, watery diarrhea, no blood, no abdominal pain
GU Decreased urine output
Skin No rash, normal turgor slightly reduced
Neuro Alert but fussy, normal tone
Diarrhea iHuman Case Study | Comprehensive
Case Study Analysis with All Sections week#- 7
,1. History of Present Illness (HPI)
An 18-month-old male is brought to the clinic by his mother due to vomiting and diarrhea for
the past 36 hours.
The vomiting began suddenly, initially with partially digested food and later became watery and
non-bilious. The child has vomited 4–5 times in the last 24 hours. Diarrhea began about 6 hours
after the onset of vomiting, described as watery, yellowish, non-bloody, occurring about 6
times per day.
Mother reports the child has been less active, irritable, and refuses solid foods, but drinks small
amounts of water and breast milk. She noticed fewer wet diapers (only 2 since morning). No
blood in stool, no recent antibiotic use, and no known food allergies. No travel or exposure to
untreated water.
There was a recent daycare outbreak of “stomach flu” in two other children.
, Associated symptoms: Mild fever (up to 38.5°C), no cough, no rash, no ear pulling, no
abdominal distension.
Aggravating factors: Eating solids or milk.
Relieving factors: None noted.
Treatment tried: Oral rehydration solution (ORS) once; vomiting followed.
2. Past Medical History
• Birth history: Full-term, normal vaginal delivery.
• Growth and development: Age-appropriate milestones.
• Past illnesses: Mild upper respiratory infections, no hospitalizations.
• Medications: None.
• Allergies: None known (NKDA).
• Immunizations: Up to date, including rotavirus vaccine.
3. Family and Social History
• Lives with parents and older sibling (4 years old, recently had mild diarrhea).
• Attends daycare 3 days per week.
• No family history of gastrointestinal disease or immune deficiency.
• No exposure to animals or recent travel.
4. Review of Systems (ROS)
System Findings
General Fever, irritability, decreased appetite, tiredness
HEENT No ear pain, no nasal congestion
Cardiac No cyanosis, no murmurs reported
Respiratory No cough, no difficulty breathing
GI Vomiting, watery diarrhea, no blood, no abdominal pain
GU Decreased urine output
Skin No rash, normal turgor slightly reduced
Neuro Alert but fussy, normal tone
