i-Human Case Study Week #4 – Pediatric Asthma Exacerbation (5-Year-Old) | Complete History, Physical Exam, Diagnosis & Plan

i-Human Case Study Week #4 – Pediatric
Asthma Exacerbation (5-Year-Old) | Complete
History, Physical Exam, Diagnosis & Plan




i-Human Case – Week #4
Patient: 5-year-old child
Height: 3'8" (112 cm)
Weight: 40.0 lb (18.2 kg)
Reason for Encounter: Cough and trouble breathing




History

Chief Complaint:
“Cough and difficulty breathing for 2 days.”

History of Present Illness (HPI):
The patient is a 5-year-old child brought by the parent with a 2-day history of persistent cough
and increasing difficulty breathing. The cough is dry, worse at night, and associated with
wheezing. Parent reports shortness of breath during play and use of accessory muscles. No
choking episodes. Symptoms worsened this morning.

Associated Symptoms:

, • Wheezing
• Chest tightness
• Fatigue
• Mild nasal congestion

Negative Symptoms:

• No fever
• No vomiting
• No cyanosis
• No chest pain

Past Medical History:

• History of recurrent wheezing episodes
• No previous hospitalizations

Birth History:

• Full-term, normal vaginal delivery

Immunizations:

• Up to date

Medications:

• None regularly

Allergies:

• No known drug allergies

Family History:

• Parent with history of asthma

Social History:

• Lives with parents
• No exposure to tobacco smoke