Pediatric Case Study
Patient Identification
• Patient Name: Michael Martinez
• Age: 18 months
• Gender: Male
• Height: 2 ft 10 in (86 cm)
• Weight: 28.0 lb (12.7 kg)
• Reason for Encounter: Cough
Title of Case Study
Assessment and Management of Persistent Cough in an 18-Month-Old Child
, Introduction
Cough is one of the most common symptoms leading to pediatric healthcare visits. In infants and
toddlers, cough may result from viral infections, allergies, asthma, environmental irritants, or
more serious respiratory illnesses such as pneumonia. Proper assessment and early management
are essential to prevent complications.
This case study discusses the assessment, diagnosis, treatment, and nursing management of
Michael Martinez, an 18-month-old child presenting with cough.
Chief Complaint
The child was brought to the clinic by his mother with complaints of:
• Persistent cough for 4 days
• Mild fever
• Nasal congestion
• Difficulty sleeping due to coughing at night
History of Present Illness
According to the mother, Michael developed a dry cough four days prior to presentation. The
cough gradually worsened and became more frequent at night. He also developed nasal
congestion and reduced appetite.
The mother reports:
• No vomiting
• No diarrhea
• Mild decrease in activity level
• Child is drinking fluids but eating less than usual
• Fever controlled temporarily with acetaminophen
There is no history of choking, foreign body aspiration, or recent travel.
Past Medical History
Patient Identification
• Patient Name: Michael Martinez
• Age: 18 months
• Gender: Male
• Height: 2 ft 10 in (86 cm)
• Weight: 28.0 lb (12.7 kg)
• Reason for Encounter: Cough
Title of Case Study
Assessment and Management of Persistent Cough in an 18-Month-Old Child
, Introduction
Cough is one of the most common symptoms leading to pediatric healthcare visits. In infants and
toddlers, cough may result from viral infections, allergies, asthma, environmental irritants, or
more serious respiratory illnesses such as pneumonia. Proper assessment and early management
are essential to prevent complications.
This case study discusses the assessment, diagnosis, treatment, and nursing management of
Michael Martinez, an 18-month-old child presenting with cough.
Chief Complaint
The child was brought to the clinic by his mother with complaints of:
• Persistent cough for 4 days
• Mild fever
• Nasal congestion
• Difficulty sleeping due to coughing at night
History of Present Illness
According to the mother, Michael developed a dry cough four days prior to presentation. The
cough gradually worsened and became more frequent at night. He also developed nasal
congestion and reduced appetite.
The mother reports:
• No vomiting
• No diarrhea
• Mild decrease in activity level
• Child is drinking fluids but eating less than usual
• Fever controlled temporarily with acetaminophen
There is no history of choking, foreign body aspiration, or recent travel.
Past Medical History
