Acute Cough in a Toddler: An i-Human
Primary Care Case Study
, i-Human Case Study Week 4
18-Month-Old Child Presenting With Cough
Patient Identification
Age: 18 months
Gender: Pediatric patient
Accompanied by: Primary caregiver
Setting: Primary Care / Outpatient Clinic
Reason for Encounter (Chief Complaint):
“Cough”
Subjective
History of Present Illness (HPI)
The patient is an 18-month-old child brought in by the caregiver for evaluation of a cough. The
caregiver reports that the cough began approximately 3 days ago and has been gradually
worsening. The cough is described as intermittent, non-productive, and occurs more frequently at
night.
Associated symptoms include nasal congestion and rhinorrhea. The caregiver denies fever,
vomiting, or diarrhea. The child has had a slightly decreased appetite, but is drinking fluids
adequately with normal urine output.
There is no history of wheezing, shortness of breath, cyanosis, choking episodes, or apnea. The
caregiver denies known exposure to ill contacts, although the child attends daycare. There has been
no recent travel and no concern for foreign body ingestion.
Past Medical History
No chronic medical conditions reported
Normal growth and development for age
Birth History
Full-term birth
No reported complications
Immunization Status
Up to date per caregiver report
Primary Care Case Study
, i-Human Case Study Week 4
18-Month-Old Child Presenting With Cough
Patient Identification
Age: 18 months
Gender: Pediatric patient
Accompanied by: Primary caregiver
Setting: Primary Care / Outpatient Clinic
Reason for Encounter (Chief Complaint):
“Cough”
Subjective
History of Present Illness (HPI)
The patient is an 18-month-old child brought in by the caregiver for evaluation of a cough. The
caregiver reports that the cough began approximately 3 days ago and has been gradually
worsening. The cough is described as intermittent, non-productive, and occurs more frequently at
night.
Associated symptoms include nasal congestion and rhinorrhea. The caregiver denies fever,
vomiting, or diarrhea. The child has had a slightly decreased appetite, but is drinking fluids
adequately with normal urine output.
There is no history of wheezing, shortness of breath, cyanosis, choking episodes, or apnea. The
caregiver denies known exposure to ill contacts, although the child attends daycare. There has been
no recent travel and no concern for foreign body ingestion.
Past Medical History
No chronic medical conditions reported
Normal growth and development for age
Birth History
Full-term birth
No reported complications
Immunization Status
Up to date per caregiver report
