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First Assessment
History & Examination
HAMI Overview
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8-year-old female with 3-day blistering rash, 4–5-day vomiting, and 2-day dyspnea, post-medication/unknown injection at an outside clinic. Associated: pruritus, restlessness, eye infection, pedal edema, abdominal pain.
HAMI Summary
HAMI — AI
Presenting Complaints
- Nausea and vomiting — 4–5 days
- Widespread rash with red blisters — 3 days
- Difficulty breathing — 2 days
- Intense itching, restlessness, and swelling/pain in feet
History of Present Illness
- Vomiting: Onset 4–5 days ago, retching and yellow vomitus. Unable to retain food, persistent nausea. Worsened after medication and injections at a local clinic.
- Rash: Developed 3 days ago — red blisters covering entire body with intense itching. No improvement despite multiple consultations; advised to seek emergency care.
- Difficulty breathing: Onset 2 days ago, ongoing, associated with severe anxiety and restlessness.
- Swelling and pain in feet, frequent urination, and constipation also reported. Abdominal pain noted, with mucus in stool.
Functional Status
- Weakness reported; patient unable to stand.
- Activity significantly limited by systemic symptoms.
Associated Symptoms
- Abdominal pain
- Frequent urination (no dysuria)
- Constipation
- Eye infection
- Restlessness
Medications
- Syrup (unspecified) — for vomiting.
- Rigix (syrup) — for restlessness; ongoing.
Aggravating / Alleviating Factors
- Restlessness and itching worsened by air exposure.
- Partial relief with covering the skin.
Initial Impression
Appearance
Breathing
Color
Not captured by scribe — clinician to assess
General Exam
General Condition
Not captured — clinician to assess
Airway
Systemic Examination HAMI — physical exam
HEENT
Not performed
Chest
Not performed
Cardiovascular
Not performed
Abdomen
Not performed
Genitalia
Not performed
Back Spine
Not performed
Neurological
Not performed
Musculoskeletal
Not performed
SAMPLE History HAMI — scribe transcript
Signs & Symptoms with Duration
Signs & Symptoms with Duration
Allergies
Allergies
Medication
Medication
Past History
Past History
Last Meal
Last Meal
Not captured by scribe — clinician to assess (constipation noted, possibly linked to reduced intake, but exact timing not stated)
Events
Events
Diagnosis
Add Diagnosis HAMI — AI assessment recommendations
Anaphylaxis T78.2
Suggested by HAMI AI · from symptom + history pattern
Provisional
Serum sickness-like reaction T80.6
Suggested by HAMI AI · from symptom + history pattern
Provisional
Urticaria with angioedema L50.0 / T78.3
Suggested by HAMI AI · from symptom + history pattern
Provisional
Erythema multiforme L51.9
Suggested by HAMI AI · from symptom + history pattern
Provisional
Early Stevens-Johnson syndrome L51.1
Suggested by HAMI AI · from symptom + history pattern
Provisional
Viral exanthem with gastroenteritis B09 / A08.4
Suggested by HAMI AI · from symptom + history pattern
Provisional
IgA vasculitis (HSP) D69.0
Suggested by HAMI AI · from symptom + history pattern
Provisional
Special Instructions
No content from scribe — clinician entry
Labs / Radiology
🧪 HAMI Recommended Labs
Search / Order Set
CBC
CRP
S. ELECTROLYTES
LFTs
S. CREATININE
Blood group
Urine C/S
URINE DR
Serum Biochemistry
Treatment
No diagnosis selected
Select a diagnosis card in the Diagnosis tab to view and order medications for this patient.
Physician Notes
💡 HAMI AI Recommendations —
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HAMI Scribe
SM
Sana Malik
Transcript
Encounter
14 Jul 2026 12:51 PM
Patient Plan
Patient plan will appear after Push to EHR.