iHuman Case Study - Pediatrics Javier
Flores 18 months CC: Cough (Latest
UPDATE) new
PATIENT INFORMATION
Field Details
Patient Name Javier Flores
Age 18 months
Sex Male
Date of Birth [Approximately 18 months prior to encounter]
Visit Date Current encounter
Chief Complaint Cough
Setting Pediatric Primary Care Clinic
Guardian/Parent Present Mother (Mrs. Flores)
CHIEF COMPLAINT (CC)
"My son has been coughing for the past 3 days."
HISTORY OF PRESENT ILLNESS (HPI)
,Narrator/Opening Scenario
Javier Flores is an 18-month-old male who presents to the pediatric clinic
accompanied by his mother with a 3-day history of cough. The mother is the
primary historian and appears appropriately concerned.
HPI Details (OLDCARTS Format)
Onset
Cough began 3 days ago gradually
No specific trigger identified
Started as dry cough, now productive-sounding
Location
Mother describes cough as "deep" and "chesty"
Seems to originate from chest rather than throat
Duration
Acute onset: 3 days total
Cough occurs throughout the day
Worse at night, disturbing sleep
Character
Initially dry, now wet/productive-sounding
Mother reports hearing "rattling" in chest
Occasionally barky quality noted
No whooping sound
No post-tussive emesis (no vomiting after cough)
Aggravating Factors
Lying flat/supine position - worse at night
Crying/active play - increases coughing episodes
, Cold air exposure - seems to trigger cough
Relieving Factors
Sitting upright provides some relief
Humidifier in room helps mildly
Warm fluids seem to soothe temporarily
Timing
Continuous throughout the day
Nocturnal worsening - significant
No specific pattern of episodes
Severity
Mother rates severity as 6/10
Not interfering with feeding significantly
No cyanosis observed
No apneic episodes
Associated Symptoms
Positive Symptoms Negative Symptoms
Low-grade fever ( Tmax 100.8°F / 38.2°C ) No high fever (>102°F)
Nasal congestion No stridor
Decreased appetite No difficulty breathing at rest
Increased fussiness No cyanosis
Mild rhinorrhea (clear) No retractions
Flores 18 months CC: Cough (Latest
UPDATE) new
PATIENT INFORMATION
Field Details
Patient Name Javier Flores
Age 18 months
Sex Male
Date of Birth [Approximately 18 months prior to encounter]
Visit Date Current encounter
Chief Complaint Cough
Setting Pediatric Primary Care Clinic
Guardian/Parent Present Mother (Mrs. Flores)
CHIEF COMPLAINT (CC)
"My son has been coughing for the past 3 days."
HISTORY OF PRESENT ILLNESS (HPI)
,Narrator/Opening Scenario
Javier Flores is an 18-month-old male who presents to the pediatric clinic
accompanied by his mother with a 3-day history of cough. The mother is the
primary historian and appears appropriately concerned.
HPI Details (OLDCARTS Format)
Onset
Cough began 3 days ago gradually
No specific trigger identified
Started as dry cough, now productive-sounding
Location
Mother describes cough as "deep" and "chesty"
Seems to originate from chest rather than throat
Duration
Acute onset: 3 days total
Cough occurs throughout the day
Worse at night, disturbing sleep
Character
Initially dry, now wet/productive-sounding
Mother reports hearing "rattling" in chest
Occasionally barky quality noted
No whooping sound
No post-tussive emesis (no vomiting after cough)
Aggravating Factors
Lying flat/supine position - worse at night
Crying/active play - increases coughing episodes
, Cold air exposure - seems to trigger cough
Relieving Factors
Sitting upright provides some relief
Humidifier in room helps mildly
Warm fluids seem to soothe temporarily
Timing
Continuous throughout the day
Nocturnal worsening - significant
No specific pattern of episodes
Severity
Mother rates severity as 6/10
Not interfering with feeding significantly
No cyanosis observed
No apneic episodes
Associated Symptoms
Positive Symptoms Negative Symptoms
Low-grade fever ( Tmax 100.8°F / 38.2°C ) No high fever (>102°F)
Nasal congestion No stridor
Decreased appetite No difficulty breathing at rest
Increased fussiness No cyanosis
Mild rhinorrhea (clear) No retractions
