Javier Flores Pediatric Cough Case Study: All-in-One Document –
CC, HPI, ROS, PE Findings, DDx, Medications, and Health Promotion
,1. PATIENT BIODATA
Category Details
Name Javier Flores
Age 18 months
Sex Male
Date of Birth Not specified
Height 2'11" (89 cm)
Weight 28.0 lb (12.7 kg)
BMI 16.1
Ethnicity Not specified
Primary Language English (assumed)
Category Details
Insurance Status Not specified
2. REASON FOR ENCOUNTER
"Cough" – Javier's mother brought him in because he has been coughing, has a fever,
and appears to be getting sicker. She is concerned about his worsening condition and
difficulty breathing.
,3. CASE INTRODUCTION
Javier Flores is an 18-month-old male who presents with a 2-day history of cough, fever,
and difficulty breathing. His mother reports progressive worsening of symptoms,
including rhinorrhea, decreased activity, and labored breathing. He has no significant
past medical history, is up to date on immunizations through 15 months, and has no
known drug allergies. Vital signs reveal fever (38.9°C/102.0°F), tachypnea (RR 40/min),
tachycardia (HR 110/min), and hypoxia (SpO₂ 92% on room air). Physical examination
shows signs of increased work of breathing and bilateral lung findings. The clinical
picture is concerning for a lower respiratory tract infection, with bronchiolitis or
pneumonia as leading considerations .
4. CHIEF COMPLAINT
"My son has been coughing and has a fever. He seems to be getting sicker."
, 5. QUESTIONS AND ANSWERS DURING FULL HISTORY
Question Response
He has been coughing and also has a fever. He seems to be
How can I help him today? getting sicker, so I thought I should have someone look at
him
Does he have any other symptoms or Yes. He has a runny nose and difficulty breathing, too. He has
been his usual self since this started.
concerns we should discuss?
How many wet diapers does your
About 4-5.
child make per day?
Does he have any allergies? None that we know of.
No, nothing prescription. I'm thinking he needs something
Is he taking any prescription medications?
though.
When did his cough start? Started 2 nights ago.
Does anything make the cough better
(Information not fully captured from available sources)
or worse?
6. HISTORY OF PRESENT ILLNESS (HPI)
Onset: Cough began approximately 2 nights ago, acute onset.
Character: Not fully documented from available sources; likely productive or dry.
Duration: 2 days.
Progression: Progressive worsening; mother reports he "seems to be getting sicker."
Associated Symptoms:
• Fever (38.9°C / 102.0°F)
CC, HPI, ROS, PE Findings, DDx, Medications, and Health Promotion
,1. PATIENT BIODATA
Category Details
Name Javier Flores
Age 18 months
Sex Male
Date of Birth Not specified
Height 2'11" (89 cm)
Weight 28.0 lb (12.7 kg)
BMI 16.1
Ethnicity Not specified
Primary Language English (assumed)
Category Details
Insurance Status Not specified
2. REASON FOR ENCOUNTER
"Cough" – Javier's mother brought him in because he has been coughing, has a fever,
and appears to be getting sicker. She is concerned about his worsening condition and
difficulty breathing.
,3. CASE INTRODUCTION
Javier Flores is an 18-month-old male who presents with a 2-day history of cough, fever,
and difficulty breathing. His mother reports progressive worsening of symptoms,
including rhinorrhea, decreased activity, and labored breathing. He has no significant
past medical history, is up to date on immunizations through 15 months, and has no
known drug allergies. Vital signs reveal fever (38.9°C/102.0°F), tachypnea (RR 40/min),
tachycardia (HR 110/min), and hypoxia (SpO₂ 92% on room air). Physical examination
shows signs of increased work of breathing and bilateral lung findings. The clinical
picture is concerning for a lower respiratory tract infection, with bronchiolitis or
pneumonia as leading considerations .
4. CHIEF COMPLAINT
"My son has been coughing and has a fever. He seems to be getting sicker."
, 5. QUESTIONS AND ANSWERS DURING FULL HISTORY
Question Response
He has been coughing and also has a fever. He seems to be
How can I help him today? getting sicker, so I thought I should have someone look at
him
Does he have any other symptoms or Yes. He has a runny nose and difficulty breathing, too. He has
been his usual self since this started.
concerns we should discuss?
How many wet diapers does your
About 4-5.
child make per day?
Does he have any allergies? None that we know of.
No, nothing prescription. I'm thinking he needs something
Is he taking any prescription medications?
though.
When did his cough start? Started 2 nights ago.
Does anything make the cough better
(Information not fully captured from available sources)
or worse?
6. HISTORY OF PRESENT ILLNESS (HPI)
Onset: Cough began approximately 2 nights ago, acute onset.
Character: Not fully documented from available sources; likely productive or dry.
Duration: 2 days.
Progression: Progressive worsening; mother reports he "seems to be getting sicker."
Associated Symptoms:
• Fever (38.9°C / 102.0°F)
