Nr 602 i-Human Case Study: Javier Flores (18 Months) –
Cough | Basic DDx SOAP Note, Differential Diagnosis &
Management 2026 PDF.
Name ; Javier Flores
Age; 18 months
Height ; 2' 10" (86 cm)
,Weight; 28.0 lb (12.7 kg)
Reason for Encounter; cough
, Chief Complaint (CC)
“He’s been coughing for a few days.”
History of Present Illness (HPI)
Mateo Rodriguez is an 18-month-old male brought in by his mother with a 3-day history of cough. The
mother reports the cough began gradually and has become more noticeable, particularly at night and
during naps. The cough is described as dry to mildly productive, without a barking or wheezing quality.
She reports associated runny nose and nasal congestion, which started around the same time as the cough.
Mateo has had no fever, difficulty breathing, cyanosis, vomiting, or choking episodes. His appetite has been
slightly decreased, but he continues to drink fluids and has normal urine output.
There is no history of foreign body aspiration, recent travel, or known exposure to COVID-19. The child
attends daycare, where several children have had recent cold-like symptoms.
No prior history of asthma, recurrent pneumonia, or chronic lung disease.
Review of Systems (ROS)
General
Denies fever, lethargy, or weight loss
HEENT
Positive for runny nose and nasal congestion
Denies ear pulling, ear discharge, sore throat
Respiratory
• Positive for cough
• Denies wheezing, shortness of breath, retractions, stridor
Cardiovascular
• Denies cyanosis or fatigue with feeding
Gastrointestinal
Cough | Basic DDx SOAP Note, Differential Diagnosis &
Management 2026 PDF.
Name ; Javier Flores
Age; 18 months
Height ; 2' 10" (86 cm)
,Weight; 28.0 lb (12.7 kg)
Reason for Encounter; cough
, Chief Complaint (CC)
“He’s been coughing for a few days.”
History of Present Illness (HPI)
Mateo Rodriguez is an 18-month-old male brought in by his mother with a 3-day history of cough. The
mother reports the cough began gradually and has become more noticeable, particularly at night and
during naps. The cough is described as dry to mildly productive, without a barking or wheezing quality.
She reports associated runny nose and nasal congestion, which started around the same time as the cough.
Mateo has had no fever, difficulty breathing, cyanosis, vomiting, or choking episodes. His appetite has been
slightly decreased, but he continues to drink fluids and has normal urine output.
There is no history of foreign body aspiration, recent travel, or known exposure to COVID-19. The child
attends daycare, where several children have had recent cold-like symptoms.
No prior history of asthma, recurrent pneumonia, or chronic lung disease.
Review of Systems (ROS)
General
Denies fever, lethargy, or weight loss
HEENT
Positive for runny nose and nasal congestion
Denies ear pulling, ear discharge, sore throat
Respiratory
• Positive for cough
• Denies wheezing, shortness of breath, retractions, stridor
Cardiovascular
• Denies cyanosis or fatigue with feeding
Gastrointestinal
