NR 602 Pediatric Cough Case Study: Evaluation and Differential
Diagnosis of an 18-Month-Old Toddler
Pediatric Case Study: 18-Month-Old Male with Cough
1. Patient Demographics & Identifying Data
Patient Initials: J.F. (Javier Flores)
Age: 18 months
Gender: Male
Ethnicity: Hispanic/Latino
Height: 2 ft 10 in (86 cm)
Weight: 28 lb (12.7 kg)
Occupation: Not applicable (toddler)
,Living Situation (Social History): Lives with both parents and an
older sibling in a smoke-free apartment. Attends daycare three
days per week.
Source of Information: Mother (primary historian), considered
reliable.
2. Chief Complaint (CC)
"My son has been coughing for the last four days and it seems
worse at night."
3. History of Present Illness (HPI) – OLD CARTS
Onset
The cough began 4 days ago after developing a runny nose.
Location
No localized pain. Symptoms involve the upper and lower
respiratory tract.
Duration
The cough occurs throughout the day but is more frequent
during the night.
Characteristics
, Dry cough that occasionally becomes productive with small
amounts of clear mucus. Mother reports nasal congestion and
intermittent wheezing.
Aggravating Factors
• Nighttime
• Running or playing
• Cold air exposure
• Lying flat
Relieving Factors
• Warm fluids
• Cool-mist humidifier
• Sitting upright
• Nasal saline with suctioning
Treatment
Mother has used:
• Saline nasal spray
• Nasal bulb suction
• Acetaminophen 160 mg orally every 6 hours as needed for
fever
• Increased oral fluids
Diagnosis of an 18-Month-Old Toddler
Pediatric Case Study: 18-Month-Old Male with Cough
1. Patient Demographics & Identifying Data
Patient Initials: J.F. (Javier Flores)
Age: 18 months
Gender: Male
Ethnicity: Hispanic/Latino
Height: 2 ft 10 in (86 cm)
Weight: 28 lb (12.7 kg)
Occupation: Not applicable (toddler)
,Living Situation (Social History): Lives with both parents and an
older sibling in a smoke-free apartment. Attends daycare three
days per week.
Source of Information: Mother (primary historian), considered
reliable.
2. Chief Complaint (CC)
"My son has been coughing for the last four days and it seems
worse at night."
3. History of Present Illness (HPI) – OLD CARTS
Onset
The cough began 4 days ago after developing a runny nose.
Location
No localized pain. Symptoms involve the upper and lower
respiratory tract.
Duration
The cough occurs throughout the day but is more frequent
during the night.
Characteristics
, Dry cough that occasionally becomes productive with small
amounts of clear mucus. Mother reports nasal congestion and
intermittent wheezing.
Aggravating Factors
• Nighttime
• Running or playing
• Cold air exposure
• Lying flat
Relieving Factors
• Warm fluids
• Cool-mist humidifier
• Sitting upright
• Nasal saline with suctioning
Treatment
Mother has used:
• Saline nasal spray
• Nasal bulb suction
• Acetaminophen 160 mg orally every 6 hours as needed for
fever
• Increased oral fluids
