Pediatric Primary Care DDx Case: Persistent Cough in an 18-
Month-Old Child
Pediatric Case Study: 18-Month-Old Male with Fever and
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 his mother, father,
and older sister in a single-family home. Attends daycare
Monday through Friday. No tobacco exposure in the home.
Source of Information: Mother, who is considered a reliable
historian.
2. Chief Complaint (CC)
"My son has had a fever and cough for the past three days and
isn't eating like he usually does."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 3 days ago with a runny nose followed by
fever and cough.
Location
Symptoms involve the upper and lower respiratory tract. No
localized pain.
Duration
The cough is present throughout the day and becomes more
frequent during the evening. Fever has occurred daily.
Characteristics
, The cough is initially dry but has become loose with occasional
mucus production. Mother reports nasal congestion, decreased
appetite, and increased fussiness.
Aggravating Factors
• Crying
• Physical activity
• Lying flat
• Nighttime
Relieving Factors
• Rest
• Acetaminophen
• Warm fluids
• Humidified air
Treatment
Mother has administered:
• Acetaminophen 160 mg orally every 6 hours as needed
• Saline nasal drops
• Nasal suctioning
• Increased oral fluids
Symptoms have improved only slightly.
Month-Old Child
Pediatric Case Study: 18-Month-Old Male with Fever and
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 his mother, father,
and older sister in a single-family home. Attends daycare
Monday through Friday. No tobacco exposure in the home.
Source of Information: Mother, who is considered a reliable
historian.
2. Chief Complaint (CC)
"My son has had a fever and cough for the past three days and
isn't eating like he usually does."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 3 days ago with a runny nose followed by
fever and cough.
Location
Symptoms involve the upper and lower respiratory tract. No
localized pain.
Duration
The cough is present throughout the day and becomes more
frequent during the evening. Fever has occurred daily.
Characteristics
, The cough is initially dry but has become loose with occasional
mucus production. Mother reports nasal congestion, decreased
appetite, and increased fussiness.
Aggravating Factors
• Crying
• Physical activity
• Lying flat
• Nighttime
Relieving Factors
• Rest
• Acetaminophen
• Warm fluids
• Humidified air
Treatment
Mother has administered:
• Acetaminophen 160 mg orally every 6 hours as needed
• Saline nasal drops
• Nasal suctioning
• Increased oral fluids
Symptoms have improved only slightly.
