iHuman Pediatric Case Study: Michael Martinez, 18-Month-
Old With Persistent Cough – Differential Diagnosis,
Pediatric Assessment, and Evidence-Based Treatment
This iHuman pediatric case study reviews Michael Martinez, an 18-month-old male presenting
with persistent cough requiring comprehensive pediatric assessment. The article discusses age-
appropriate clinical evaluation, key differential diagnoses including viral bronchiolitis,
pneumonia, asthma, croup, and foreign body aspiration, and outlines evidence-based treatment
and management strategies for pediatric cough in toddlers.
iHuman pediatric case,
18 month old coughing,
pediatric cough differential diagnosis,
toddler cough assessment,
,Patient Information
• Name: Michael Martinez
• Age: 18 months
• Sex: Male
• Chief Complaint (CC): “He has been coughing for several days.”
S – Subjective
History of Present Illness (HPI)
Michael Martinez is an 18-month-old male brought in by his mother due to a persistent cough
that began 4 days ago. The cough is described as dry initially, becoming more productive over
the past 24 hours. The mother reports the cough is worse at night and occasionally causes the
child to wake from sleep. She notes mild nasal congestion and rhinorrhea, but denies fever
higher than 100.4°F.
The mother reports decreased appetite, though fluid intake has remained adequate. There has
been no vomiting, no diarrhea, and no choking episodes. No known exposure to COVID-19,
but the child attends daycare where other children have had “colds.” No wheezing has been
noted by the mother, but she reports hearing “noisy breathing” at times.
Associated Symptoms
• Positive: cough, nasal congestion, runny nose, mild irritability
• Negative: high fever, cyanosis, apnea, vomiting, diarrhea, rash
,Past Medical History
• Full-term vaginal delivery
• No complications at birth
• No prior hospitalizations
• No history of asthma or chronic lung disease
Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Immunization Status
• Up to date per CDC schedule
Family History
• No family history of asthma
• No history of congenital heart or lung disease
Social History
• Lives with parents
• Attends daycare
• No exposure to tobacco smoke at home
O – Objective
Vital Signs
• Temperature: 99.1°F (37.3°C)
• Heart Rate: 118 bpm
• Respiratory Rate: 28 breaths/min
• Blood Pressure: 90/55 mmHg
• Oxygen Saturation: 96% on room air
, • Weight: Appropriate for age
General Appearance
Alert, mildly irritable toddler in no acute distress. Active and responsive to caregiver.
HEENT
• Head: Normocephalic, atraumatic
• Eyes: Clear conjunctiva, no discharge
• Ears: Tympanic membranes intact, no erythema or bulging
• Nose: Nasal congestion with clear rhinorrhea
• Throat: Mild pharyngeal erythema, no tonsillar exudate
Neck
Supple, no lymphadenopathy
Respiratory
• Mild intercostal retractions
• Breath sounds: Scattered rhonchi, mild wheezing bilaterally
• No crackles
• No stridor
Cardiovascular
• Regular rate and rhythm
• No murmurs
• Capillary refill <2 seconds
Abdomen
• Soft, non-tender
• No hepatosplenomegaly
Skin
• Warm, dry
• No rash or cyanosis
Neurological
• Alert
• Appropriate for age
Old With Persistent Cough – Differential Diagnosis,
Pediatric Assessment, and Evidence-Based Treatment
This iHuman pediatric case study reviews Michael Martinez, an 18-month-old male presenting
with persistent cough requiring comprehensive pediatric assessment. The article discusses age-
appropriate clinical evaluation, key differential diagnoses including viral bronchiolitis,
pneumonia, asthma, croup, and foreign body aspiration, and outlines evidence-based treatment
and management strategies for pediatric cough in toddlers.
iHuman pediatric case,
18 month old coughing,
pediatric cough differential diagnosis,
toddler cough assessment,
,Patient Information
• Name: Michael Martinez
• Age: 18 months
• Sex: Male
• Chief Complaint (CC): “He has been coughing for several days.”
S – Subjective
History of Present Illness (HPI)
Michael Martinez is an 18-month-old male brought in by his mother due to a persistent cough
that began 4 days ago. The cough is described as dry initially, becoming more productive over
the past 24 hours. The mother reports the cough is worse at night and occasionally causes the
child to wake from sleep. She notes mild nasal congestion and rhinorrhea, but denies fever
higher than 100.4°F.
The mother reports decreased appetite, though fluid intake has remained adequate. There has
been no vomiting, no diarrhea, and no choking episodes. No known exposure to COVID-19,
but the child attends daycare where other children have had “colds.” No wheezing has been
noted by the mother, but she reports hearing “noisy breathing” at times.
Associated Symptoms
• Positive: cough, nasal congestion, runny nose, mild irritability
• Negative: high fever, cyanosis, apnea, vomiting, diarrhea, rash
,Past Medical History
• Full-term vaginal delivery
• No complications at birth
• No prior hospitalizations
• No history of asthma or chronic lung disease
Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Immunization Status
• Up to date per CDC schedule
Family History
• No family history of asthma
• No history of congenital heart or lung disease
Social History
• Lives with parents
• Attends daycare
• No exposure to tobacco smoke at home
O – Objective
Vital Signs
• Temperature: 99.1°F (37.3°C)
• Heart Rate: 118 bpm
• Respiratory Rate: 28 breaths/min
• Blood Pressure: 90/55 mmHg
• Oxygen Saturation: 96% on room air
, • Weight: Appropriate for age
General Appearance
Alert, mildly irritable toddler in no acute distress. Active and responsive to caregiver.
HEENT
• Head: Normocephalic, atraumatic
• Eyes: Clear conjunctiva, no discharge
• Ears: Tympanic membranes intact, no erythema or bulging
• Nose: Nasal congestion with clear rhinorrhea
• Throat: Mild pharyngeal erythema, no tonsillar exudate
Neck
Supple, no lymphadenopathy
Respiratory
• Mild intercostal retractions
• Breath sounds: Scattered rhonchi, mild wheezing bilaterally
• No crackles
• No stridor
Cardiovascular
• Regular rate and rhythm
• No murmurs
• Capillary refill <2 seconds
Abdomen
• Soft, non-tender
• No hepatosplenomegaly
Skin
• Warm, dry
• No rash or cyanosis
Neurological
• Alert
• Appropriate for age
