,i-HUMAN CASE STUDY: COMMUNITY-ACQUIRED PNEUMONIA
(PRESUMED BACTERIAL) – 18-MONTH-OLD
Case ID: PED-CAP-2402
Target Audience: Medical students, NP, PA, and pediatric clerkship learners
Setting: Outpatient pediatric clinic (labs, CXR available)
▶ PATIENT INFORMATION
Demographics Details
Name Michael Martinez
Age 18 months
Gender Male
Weight 11.5 kg (~25.4 lb) – ~40th percentile
Length 81 cm (~31.9 in)
Born full-term, uncomplicated; immunizations up-to-date (including PCV13, Hib, DTaP,
PMH MMR, Varicella, HepA); no history of reactive airway disease, asthma, or immunodeficiency;
has had “a couple of colds over the past few months” but none as severe as this.
Allergies None known (NKDA)
, Demographics Details
Acetaminophen (Tylenol) 2–3 times/day – mother cannot recall dose; child often spits it out.
Medications
No prescription medications.
Family
Non-contributory; no cystic fibrosis, primary ciliary dyskinesia, or immune deficiency.
History
Lives with mother and father. Father smokes at home (secondhand smoke exposure daily).
Social History
Attends daycare where several children have been sick recently. No pets.
▶ REASON FOR ENCOUNTER
(Presented by Michael’s mother)
“He has been coughing and also has fever. He seems to be getting sicker, so I thought I should
have someone look at him.”
▶ HISTORY OF PRESENT ILLNESS (HPI) – VERBATIM FROM iHUMAN
TRANSCRIPT
The following questions and answers are taken directly from the learner’s iHuman interview
with Michael’s mother. These should be used to teach clinical reasoning and history-taking.
# Question Mother’s Response
He has been coughing and also has fever. He seems to be getting sicker
1 How can I help him today?
so I thought I should have someone look at him.
(PRESUMED BACTERIAL) – 18-MONTH-OLD
Case ID: PED-CAP-2402
Target Audience: Medical students, NP, PA, and pediatric clerkship learners
Setting: Outpatient pediatric clinic (labs, CXR available)
▶ PATIENT INFORMATION
Demographics Details
Name Michael Martinez
Age 18 months
Gender Male
Weight 11.5 kg (~25.4 lb) – ~40th percentile
Length 81 cm (~31.9 in)
Born full-term, uncomplicated; immunizations up-to-date (including PCV13, Hib, DTaP,
PMH MMR, Varicella, HepA); no history of reactive airway disease, asthma, or immunodeficiency;
has had “a couple of colds over the past few months” but none as severe as this.
Allergies None known (NKDA)
, Demographics Details
Acetaminophen (Tylenol) 2–3 times/day – mother cannot recall dose; child often spits it out.
Medications
No prescription medications.
Family
Non-contributory; no cystic fibrosis, primary ciliary dyskinesia, or immune deficiency.
History
Lives with mother and father. Father smokes at home (secondhand smoke exposure daily).
Social History
Attends daycare where several children have been sick recently. No pets.
▶ REASON FOR ENCOUNTER
(Presented by Michael’s mother)
“He has been coughing and also has fever. He seems to be getting sicker, so I thought I should
have someone look at him.”
▶ HISTORY OF PRESENT ILLNESS (HPI) – VERBATIM FROM iHUMAN
TRANSCRIPT
The following questions and answers are taken directly from the learner’s iHuman interview
with Michael’s mother. These should be used to teach clinical reasoning and history-taking.
# Question Mother’s Response
He has been coughing and also has fever. He seems to be getting sicker
1 How can I help him today?
so I thought I should have someone look at him.
