Primary Care Pediatric Case Study: Acute Cough in an 18-
Month-Old Male
Pediatric Case Study: 18-Month-Old Male with Hand, Foot, and Mouth
Disease
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 parents and older sister
in a smoke-free home. Attends daycare five days per week where
several children have recently been ill.
Source of Information: Mother, who is considered a reliable historian.
2. Chief Complaint (CC)
"My son has a fever, painful sores in his mouth, and a rash on his
hands and feet."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 3 days ago with a low-grade fever followed by
decreased appetite. A rash developed on the hands and feet one day
later.
Location
Painful sores are located inside the mouth and on the tongue. Rash is
present on the palms of the hands, soles of the feet, and around the
mouth.
Duration
Symptoms have been continuous for the past three days.
Characteristics
Mother reports fever, painful oral ulcers, drooling, refusal to eat solid
foods, irritability, and a red blister-like rash on the hands and feet.
Month-Old Male
Pediatric Case Study: 18-Month-Old Male with Hand, Foot, and Mouth
Disease
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 parents and older sister
in a smoke-free home. Attends daycare five days per week where
several children have recently been ill.
Source of Information: Mother, who is considered a reliable historian.
2. Chief Complaint (CC)
"My son has a fever, painful sores in his mouth, and a rash on his
hands and feet."
3. History of Present Illness (HPI) – OLD CARTS Method
Onset
Symptoms began 3 days ago with a low-grade fever followed by
decreased appetite. A rash developed on the hands and feet one day
later.
Location
Painful sores are located inside the mouth and on the tongue. Rash is
present on the palms of the hands, soles of the feet, and around the
mouth.
Duration
Symptoms have been continuous for the past three days.
Characteristics
Mother reports fever, painful oral ulcers, drooling, refusal to eat solid
foods, irritability, and a red blister-like rash on the hands and feet.
