i-Human Week 4: 18-Month-Old with Cough (NRNP 6541) Case Study
,SECTION 1: Electronic Health Record (EHR) Intake & Clinical Demographics
Age: 18 months
Gender: Male
Height: 2' 10" (86 cm)
Weight: 28.0 lbs (12.7 kg)
Allergies: No Known Drug Allergies (NKDA)
Chief Complaint (CC): "Harsh, barking cough that worsened suddenly overnight."
SECTION 2: Comprehensive History of Present Illness (HPI)
The patient is an 18-month-old male who presents to the clinic accompanied by his mother
due to a acute onset of a harsh, barking cough.
Onset: The illness began 3 days ago with mild upper respiratory symptoms,
including clear rhinorrhea and intermittent sneezing. The characteristic barking
cough developed acutely last night.
Location: Upper respiratory tract and subglottic airway.
Duration: 3 days total duration; acute exacerbation over the past 12 hours.
Characteristics: Cough is described as sounding like a "seal barking." It is harsh,
spasmodic, and worsens significantly when the child cries or becomes agitated.
Aggravating Factors: Crying, agitation, laying flat in the crib.
, Alleviating Factors: Brief improvement noted when the mother took the child
outside into the cool night air.
Radiation: Not applicable.
Timing: Symptoms are significantly worse at night and during early morning hours.
Severity: Moderate distress. The child is alert but irritable when disturbed.
SECTION 3: Review of Systems (ROS)
General: Positive for low-grade fever ($100.6^\circ\text{F} / 38.1^\circ\text{C}$) and
mild irritability. Negative for lethargy, weight loss, or chills.
HEENT: Positive for clear nasal discharge and mild pharyngeal redness. Negative
for ear tugging, conjunctival injection, or drooling.
Respiratory: Positive for barking cough, mild tachypnea, and intermittent inspiratory
stridor when agitated. Negative for expiratory wheezing, grunting, or apneas.
Cardiovascular: Positive for mild tachycardia (consistent with fever and agitation).
Negative for cyanosis or mottled skin.
Gastrointestinal: Decreased appetite secondary to respiratory effort, but
maintaining adequate fluid intake. Negative for vomiting, diarrhea, or abdominal pain.
Genitourinary: Normal urine output (5 wet diapers in the last 24 hours).
Musculoskeletal: Normal range of motion. Negative for hypotonia.
Integumentary: Skin warm and dry. Negative for rashes or hives.
SECTION 4: Medical, Family, and Social History (PMH, FH, SH)
,SECTION 1: Electronic Health Record (EHR) Intake & Clinical Demographics
Age: 18 months
Gender: Male
Height: 2' 10" (86 cm)
Weight: 28.0 lbs (12.7 kg)
Allergies: No Known Drug Allergies (NKDA)
Chief Complaint (CC): "Harsh, barking cough that worsened suddenly overnight."
SECTION 2: Comprehensive History of Present Illness (HPI)
The patient is an 18-month-old male who presents to the clinic accompanied by his mother
due to a acute onset of a harsh, barking cough.
Onset: The illness began 3 days ago with mild upper respiratory symptoms,
including clear rhinorrhea and intermittent sneezing. The characteristic barking
cough developed acutely last night.
Location: Upper respiratory tract and subglottic airway.
Duration: 3 days total duration; acute exacerbation over the past 12 hours.
Characteristics: Cough is described as sounding like a "seal barking." It is harsh,
spasmodic, and worsens significantly when the child cries or becomes agitated.
Aggravating Factors: Crying, agitation, laying flat in the crib.
, Alleviating Factors: Brief improvement noted when the mother took the child
outside into the cool night air.
Radiation: Not applicable.
Timing: Symptoms are significantly worse at night and during early morning hours.
Severity: Moderate distress. The child is alert but irritable when disturbed.
SECTION 3: Review of Systems (ROS)
General: Positive for low-grade fever ($100.6^\circ\text{F} / 38.1^\circ\text{C}$) and
mild irritability. Negative for lethargy, weight loss, or chills.
HEENT: Positive for clear nasal discharge and mild pharyngeal redness. Negative
for ear tugging, conjunctival injection, or drooling.
Respiratory: Positive for barking cough, mild tachypnea, and intermittent inspiratory
stridor when agitated. Negative for expiratory wheezing, grunting, or apneas.
Cardiovascular: Positive for mild tachycardia (consistent with fever and agitation).
Negative for cyanosis or mottled skin.
Gastrointestinal: Decreased appetite secondary to respiratory effort, but
maintaining adequate fluid intake. Negative for vomiting, diarrhea, or abdominal pain.
Genitourinary: Normal urine output (5 wet diapers in the last 24 hours).
Musculoskeletal: Normal range of motion. Negative for hypotonia.
Integumentary: Skin warm and dry. Negative for rashes or hives.
SECTION 4: Medical, Family, and Social History (PMH, FH, SH)
