PERSISTENT COUGH AND TROUBLE BREATHING AT PEDIATRIC
OUTPATIENT CLINIC UTILIZING SYSTEMATIC HISTORY, PHYSICAL
EXAMINATION, DIFFERENTIAL DIAGNOSIS, AND EVIDENCE-BASED
MANAGEMENT
,PATIENT INFORMATION
Age: 5 years
Sex: Male
Height: ~3′8″ (approximately typical for age)
Weight: ~40 lb (approximate for age)
Location: Pediatric outpatient clinic
Reason for Encounter: Cough and trouble breathing
Explanation:
A 5-year-old boy is brought by his caregiver to the pediatric outpatient clinic for evaluation of a
persistent cough and difficulty breathing that has worsened over the past few days. This visit
focuses on assessing respiratory status, identifying a likely etiology such as asthma or infection,
and instituting appropriate evidence-based treatment.
, REASON FOR ENCOUNTER
Category Details
Encounter Type Pediatric outpatient clinical visit
Chief Complaint Cough and trouble breathing
Duration ~3 to 4 days
Frequency Persistent coughing throughout the day
Associated
Wheezing, mild shortness of breath, occasional nighttime worsening
Symptoms
Physical activity, lying flat, nighttime
Aggravating Factors
Relieving Factors Sitting upright, resting, nebulizer use
Low-grade fever, no vomiting or diarrhea, no altered level of
Systemic Symptoms
consciousness
Determine cause of symptoms, ease breathing effort, return to normal
Patient Goals
activity
Explanation:
The caregiver reports her 5-year-old son has had persistent cough and trouble breathing for
the past several days. Symptoms include wheezing and increased work of breathing, especially
at night and after activity. There is a low-grade fever but no systemic red-flag symptoms such as
high fever, lethargy, or confusion. The family seeks an explanation for his symptoms and relief.