COMPLETE I HUMAN LATEST
CASE WEEK #4
18MONTH OLD
CHILD REASON FOR
ENCOUNTER:
COUGH
END OF
PAGE
1
,COMPLETE I HUMAN LATEST
CASE WEEK #4
18MONTH OLD
CHILD REASON FOR
ENCOUNTER:
COUGH
HPI STATEMENT
The patient is an 18-month-old child who presents today accompanied
by the parent with a chief complaint of cough. According to the parent,
the cough began 3 days ago and has been gradually worsening. The
cough is described as intermittent and dry, occurring more frequently
at night and occasionally waking the child from sleep. The parent
reports that the cough is not productive, with no sputum production
noted.
The parent denies any history of choking episodes or foreign body
aspiration. There is no associated wheezing, stridor, or shortness of
breath. The child has had low-grade subjective fever at home but no
documented high fever. There is associated nasal congestion and clear
rhinorrhea, but no ear pulling, ear discharge, or sore throat noted.
The child has had normal oral intake, with no vomiting or diarrhea,
and normal urine output. There has been no cyanosis, apnea, or
lethargy. The parent denies rash or exposure to known allergens. There
is no known exposure to tuberculosis and no recent travel. The child
END OF
PAGE
2
, COMPLETE I HUMAN LATEST
CASE WEEK #4
18MONTH OLD
CHILD REASON FOR
ENCOUNTER:
COUGH
does not attend daycare, but there has been a recent upper
respiratory infection in a household contact.
The child was born full term, is up to date on immunizations, and has
no history of asthma or chronic lung disease. No medications have
been given for the current illness other than occasional acetaminophen,
with mild relief of fever but no change in cough severity.
HISTORY OF PRESENT ILLNESS
HPI Domain /
Exact Question Asked Parent’s Response
Approach
What brings your child in My child has been
Chief Concern
today? coughing.
Onset When did the cough start? It started about 3 days
END OF
PAGE
3
CASE WEEK #4
18MONTH OLD
CHILD REASON FOR
ENCOUNTER:
COUGH
END OF
PAGE
1
,COMPLETE I HUMAN LATEST
CASE WEEK #4
18MONTH OLD
CHILD REASON FOR
ENCOUNTER:
COUGH
HPI STATEMENT
The patient is an 18-month-old child who presents today accompanied
by the parent with a chief complaint of cough. According to the parent,
the cough began 3 days ago and has been gradually worsening. The
cough is described as intermittent and dry, occurring more frequently
at night and occasionally waking the child from sleep. The parent
reports that the cough is not productive, with no sputum production
noted.
The parent denies any history of choking episodes or foreign body
aspiration. There is no associated wheezing, stridor, or shortness of
breath. The child has had low-grade subjective fever at home but no
documented high fever. There is associated nasal congestion and clear
rhinorrhea, but no ear pulling, ear discharge, or sore throat noted.
The child has had normal oral intake, with no vomiting or diarrhea,
and normal urine output. There has been no cyanosis, apnea, or
lethargy. The parent denies rash or exposure to known allergens. There
is no known exposure to tuberculosis and no recent travel. The child
END OF
PAGE
2
, COMPLETE I HUMAN LATEST
CASE WEEK #4
18MONTH OLD
CHILD REASON FOR
ENCOUNTER:
COUGH
does not attend daycare, but there has been a recent upper
respiratory infection in a household contact.
The child was born full term, is up to date on immunizations, and has
no history of asthma or chronic lung disease. No medications have
been given for the current illness other than occasional acetaminophen,
with mild relief of fever but no change in cough severity.
HISTORY OF PRESENT ILLNESS
HPI Domain /
Exact Question Asked Parent’s Response
Approach
What brings your child in My child has been
Chief Concern
today? coughing.
Onset When did the cough start? It started about 3 days
END OF
PAGE
3
