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A 5-Year-Old Patient With Cough and Trouble Breathing
(Class 6541): Complete Clinical Analysis and Case Study
This complete case study analyzes a 5-year-old pediatric patient presenting with cough and
trouble breathing. Developed for Class 6541, the article covers clinical assessment, differential
diagnosis, diagnostic considerations, and evidence-based treatment strategies for pediatric
respiratory distress.
5 year old cough and trouble breathing,
pediatric respiratory distress case study,
Class 6541 pediatric case,
child cough differential diagnosis,
Patient Information
, • Age: 5 years
• Gender: Male
• Chief Complaint: “My child has been coughing and is having trouble breathing.”
S – Subjective
History of Present Illness (HPI)
The patient is a 5-year-old male who presents with a 3-day history of cough and progressive
difficulty breathing. The cough is described as persistent and non-productive. Symptoms worsened
over the past 24 hours, particularly at night. The caregiver reports associated shortness of breath,
wheezing, and fatigue. No episodes of choking were reported. The child has had a low-grade fever
(maximum 100.8°F) at home.
There is no chest pain, no cyanosis, and no vomiting. Appetite has decreased slightly, but the child
continues to drink fluids. No recent travel. There is a history of exposure to a sibling with a recent
upper respiratory infection.
Past Medical History
• Mild intermittent asthma diagnosed at age 3
• No hospitalizations or intubations
Birth History
• Full-term vaginal delivery
• No neonatal complications
Medications
• Albuterol inhaler as needed (used twice in the last 24 hours with partial relief)
Allergies
• No known drug allergies
Immunization Status
• Up to date per CDC guidelines
Family History
• Mother with asthma
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• No family history of congenital heart disease
Social History
• Lives with parents and two siblings
• No exposure to tobacco smoke
• Attends kindergarten
Review of Systems (ROS)
• General: Fever, fatigue
• Respiratory: Cough, wheezing, shortness of breath
• ENT: Mild nasal congestion
• Cardiovascular: Denies palpitations or cyanosis
• GI: No nausea, vomiting, or diarrhea
O – Objective
Vital Signs
• Temperature: 100.6°F (38.1°C)
• Heart Rate: 118 bpm
• Respiratory Rate: 30 breaths/min
• Blood Pressure: 98/60 mmHg
• Oxygen Saturation: 93% on room air
General Appearance
• Alert but fatigued
• Mild respiratory distress noted
HEENT
• Nasal mucosa mildly congested
• Oropharynx clear, no tonsillar exudate
Neck
• Supple, no lymphadenopathy
Respiratory
• Increased work of breathing
, • Mild intercostal retractions
• Diffuse expiratory wheezes bilaterally
• Prolonged expiratory phase
• No crackles or stridor
Cardiovascular
• Tachycardic, regular rhythm
• No murmurs, rubs, or gallops
Abdomen
• Soft, non-tender, non-distended
Skin
• Warm, no cyanosis or rash
Neurological
• Alert and oriented for age
A – Assessment
Primary Diagnosis
Acute Asthma Exacerbation triggered by Viral Upper Respiratory Infection
Differential Diagnoses
1. Viral Bronchitis – cough and URI symptoms but wheezing suggests asthma
2. Pneumonia – less likely due to absence of focal crackles and high fever
3. Croup – unlikely due to absence of barking cough or stridor
4. Foreign Body Aspiration – no sudden onset or choking history
Clinical Reasoning
The patient’s history of asthma, wheezing, increased work of breathing, and partial response to
albuterol strongly support an asthma exacerbation. Viral infection is the most likely trigger.
P – Plan
A 5-Year-Old Patient With Cough and Trouble Breathing
(Class 6541): Complete Clinical Analysis and Case Study
This complete case study analyzes a 5-year-old pediatric patient presenting with cough and
trouble breathing. Developed for Class 6541, the article covers clinical assessment, differential
diagnosis, diagnostic considerations, and evidence-based treatment strategies for pediatric
respiratory distress.
5 year old cough and trouble breathing,
pediatric respiratory distress case study,
Class 6541 pediatric case,
child cough differential diagnosis,
Patient Information
, • Age: 5 years
• Gender: Male
• Chief Complaint: “My child has been coughing and is having trouble breathing.”
S – Subjective
History of Present Illness (HPI)
The patient is a 5-year-old male who presents with a 3-day history of cough and progressive
difficulty breathing. The cough is described as persistent and non-productive. Symptoms worsened
over the past 24 hours, particularly at night. The caregiver reports associated shortness of breath,
wheezing, and fatigue. No episodes of choking were reported. The child has had a low-grade fever
(maximum 100.8°F) at home.
There is no chest pain, no cyanosis, and no vomiting. Appetite has decreased slightly, but the child
continues to drink fluids. No recent travel. There is a history of exposure to a sibling with a recent
upper respiratory infection.
Past Medical History
• Mild intermittent asthma diagnosed at age 3
• No hospitalizations or intubations
Birth History
• Full-term vaginal delivery
• No neonatal complications
Medications
• Albuterol inhaler as needed (used twice in the last 24 hours with partial relief)
Allergies
• No known drug allergies
Immunization Status
• Up to date per CDC guidelines
Family History
• Mother with asthma
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• No family history of congenital heart disease
Social History
• Lives with parents and two siblings
• No exposure to tobacco smoke
• Attends kindergarten
Review of Systems (ROS)
• General: Fever, fatigue
• Respiratory: Cough, wheezing, shortness of breath
• ENT: Mild nasal congestion
• Cardiovascular: Denies palpitations or cyanosis
• GI: No nausea, vomiting, or diarrhea
O – Objective
Vital Signs
• Temperature: 100.6°F (38.1°C)
• Heart Rate: 118 bpm
• Respiratory Rate: 30 breaths/min
• Blood Pressure: 98/60 mmHg
• Oxygen Saturation: 93% on room air
General Appearance
• Alert but fatigued
• Mild respiratory distress noted
HEENT
• Nasal mucosa mildly congested
• Oropharynx clear, no tonsillar exudate
Neck
• Supple, no lymphadenopathy
Respiratory
• Increased work of breathing
, • Mild intercostal retractions
• Diffuse expiratory wheezes bilaterally
• Prolonged expiratory phase
• No crackles or stridor
Cardiovascular
• Tachycardic, regular rhythm
• No murmurs, rubs, or gallops
Abdomen
• Soft, non-tender, non-distended
Skin
• Warm, no cyanosis or rash
Neurological
• Alert and oriented for age
A – Assessment
Primary Diagnosis
Acute Asthma Exacerbation triggered by Viral Upper Respiratory Infection
Differential Diagnoses
1. Viral Bronchitis – cough and URI symptoms but wheezing suggests asthma
2. Pneumonia – less likely due to absence of focal crackles and high fever
3. Croup – unlikely due to absence of barking cough or stridor
4. Foreign Body Aspiration – no sudden onset or choking history
Clinical Reasoning
The patient’s history of asthma, wheezing, increased work of breathing, and partial response to
albuterol strongly support an asthma exacerbation. Viral infection is the most likely trigger.
P – Plan
