I-HUMAN CASE STUDY: MICHAEL MARTINEZ — 18-
MONTH-OLD CHILD WITH ACUTE COUGH AND
RESPIRATORY DISTRESS
PATIENT OVERVIEW
• Name: Michael Martinez
• Age: 18 months
• Gender: Male
• Chief Complaint: Cough and difficulty breathing
• Accompanied by: Mother
• Setting: Outpatient / Primary care pediatric visit
SUBJECTIVE DATA (HPI)
Michael Martinez is an 18-month-old male brought in by his mother due to a worsening cough and
breathing difficulty.
• Onset: Cough began 2 days ago
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, • Character: Productive cough with thick yellow sputum
• Associated Symptoms:
o Fever for 2 days (maximum reported temperature 102°F / 38.9°C)
o Nasal congestion and rhinorrhea for approximately 5 days
o Decreased appetite
o Increased work of breathing
• Home Management: Mother has been giving acetaminophen intermittently; dosing
inconsistent due to difficulty administering medication
• Hydration: Producing approximately 4–5 wet diapers per day
• Exposure History: Significant second-hand smoke exposure (father smokes inside the home)
• Immunization Status: Up to date
• Past Medical History: No chronic illness reported
• Allergies: None reported
REVIEW OF SYSTEMS (ROS)
• General: Fever, irritability, decreased appetite
• HEENT: Nasal congestion, rhinorrhea
• Respiratory: Cough, wheezing, labored breathing
• Cardiac: No cyanosis reported
• GI: No vomiting or diarrhea
• GU: Adequate urine output
• Skin: No rash
• Neurological: Alert but irritable
OBJECTIVE DATA
Vital Signs
• Temperature: 102°F (38.9°C)
• Heart Rate: ~110 bpm
• Respiratory Rate: ~40 breaths/min
• Oxygen Saturation: ~92% on room air
General Appearance
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MONTH-OLD CHILD WITH ACUTE COUGH AND
RESPIRATORY DISTRESS
PATIENT OVERVIEW
• Name: Michael Martinez
• Age: 18 months
• Gender: Male
• Chief Complaint: Cough and difficulty breathing
• Accompanied by: Mother
• Setting: Outpatient / Primary care pediatric visit
SUBJECTIVE DATA (HPI)
Michael Martinez is an 18-month-old male brought in by his mother due to a worsening cough and
breathing difficulty.
• Onset: Cough began 2 days ago
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, • Character: Productive cough with thick yellow sputum
• Associated Symptoms:
o Fever for 2 days (maximum reported temperature 102°F / 38.9°C)
o Nasal congestion and rhinorrhea for approximately 5 days
o Decreased appetite
o Increased work of breathing
• Home Management: Mother has been giving acetaminophen intermittently; dosing
inconsistent due to difficulty administering medication
• Hydration: Producing approximately 4–5 wet diapers per day
• Exposure History: Significant second-hand smoke exposure (father smokes inside the home)
• Immunization Status: Up to date
• Past Medical History: No chronic illness reported
• Allergies: None reported
REVIEW OF SYSTEMS (ROS)
• General: Fever, irritability, decreased appetite
• HEENT: Nasal congestion, rhinorrhea
• Respiratory: Cough, wheezing, labored breathing
• Cardiac: No cyanosis reported
• GI: No vomiting or diarrhea
• GU: Adequate urine output
• Skin: No rash
• Neurological: Alert but irritable
OBJECTIVE DATA
Vital Signs
• Temperature: 102°F (38.9°C)
• Heart Rate: ~110 bpm
• Respiratory Rate: ~40 breaths/min
• Oxygen Saturation: ~92% on room air
General Appearance
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