IHUMAN WEEK 4 CASE STUDY: GRADY TURNER AN
18-MONTH-OLD MALE WITH BARKING COUGH:
DIAGNOSIS, SEVERITY ASSESSMENT, AND
MANAGEMENT OF CROUP
,PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Grady Turner
Age 18 months old
Gender Male
Ethnicity [To be specified in case]
Date of Birth [To be specified]
Date of Visit [Current date]
Source Parent (mother/father) – primary historian
Reliability Parent is reliable; child may be distressed but able to be examined
Allergies No Known Drug Allergies (NKDA) – confirm
Chief Complaint: "Barking cough" or "He has a cough that sounds like a seal barking"
Encounter Type: Urgent Care, Emergency Department, or Outpatient Clinic (depending
on severity)
PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance
Any previous Recurrent croup may suggest anatomic airwa
Prior croup episodes
episodes? issues
, Condition Details Relevance
Asthma/reactive airway
Any diagnosis? Differentiates from croup; impacts managem
disease
Gestational age at
Prematurity Prematurity increases risk for respiratory illne
birth?
Intubation history Any prior intubations? Airway scarring may predispose to stridor
GERD Any reflux symptoms? Can mimic or exacerbate respiratory sympto
Hib vaccine prevents epiglottitis; MMR preve
Immunizations Up to date?
measles
Key Questions:
Has Grady ever had croup before?
Was he born full-term?
Any history of breathing problems, asthma, or wheezing?
Any known allergies?
Are his immunizations up to date?
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Details
None No prior surgeries – typical for 18-month-old
PART 4: MEDICATIONS
Current Medications
, Medication Dose Frequency Prescriber Purpose
None N/A N/A N/A N/A
Key Questions:
Any medications given at home for this illness? (acetaminophen, ibuprofen, cough/cold
medicines – avoid in young children)
Any nebulizer treatments or steroids?
PART 5: FAMILY HISTORY
Relative Age/Status Medical Conditions
Mother [Age] Asthma? Allergies?
Father [Age] Asthma? Allergies?
Siblings [Ages] Any history of croup? Asthma?
Others
Key Questions:
Family history of croup, asthma, or reactive airway disease?
Family history of allergies or eczema?
PART 6: SOCIAL HISTORY
Factor Details Relevance
Daycare Common exposure source for viral
Attends daycare?
attendance infections
18-MONTH-OLD MALE WITH BARKING COUGH:
DIAGNOSIS, SEVERITY ASSESSMENT, AND
MANAGEMENT OF CROUP
,PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Grady Turner
Age 18 months old
Gender Male
Ethnicity [To be specified in case]
Date of Birth [To be specified]
Date of Visit [Current date]
Source Parent (mother/father) – primary historian
Reliability Parent is reliable; child may be distressed but able to be examined
Allergies No Known Drug Allergies (NKDA) – confirm
Chief Complaint: "Barking cough" or "He has a cough that sounds like a seal barking"
Encounter Type: Urgent Care, Emergency Department, or Outpatient Clinic (depending
on severity)
PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance
Any previous Recurrent croup may suggest anatomic airwa
Prior croup episodes
episodes? issues
, Condition Details Relevance
Asthma/reactive airway
Any diagnosis? Differentiates from croup; impacts managem
disease
Gestational age at
Prematurity Prematurity increases risk for respiratory illne
birth?
Intubation history Any prior intubations? Airway scarring may predispose to stridor
GERD Any reflux symptoms? Can mimic or exacerbate respiratory sympto
Hib vaccine prevents epiglottitis; MMR preve
Immunizations Up to date?
measles
Key Questions:
Has Grady ever had croup before?
Was he born full-term?
Any history of breathing problems, asthma, or wheezing?
Any known allergies?
Are his immunizations up to date?
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Details
None No prior surgeries – typical for 18-month-old
PART 4: MEDICATIONS
Current Medications
, Medication Dose Frequency Prescriber Purpose
None N/A N/A N/A N/A
Key Questions:
Any medications given at home for this illness? (acetaminophen, ibuprofen, cough/cold
medicines – avoid in young children)
Any nebulizer treatments or steroids?
PART 5: FAMILY HISTORY
Relative Age/Status Medical Conditions
Mother [Age] Asthma? Allergies?
Father [Age] Asthma? Allergies?
Siblings [Ages] Any history of croup? Asthma?
Others
Key Questions:
Family history of croup, asthma, or reactive airway disease?
Family history of allergies or eczema?
PART 6: SOCIAL HISTORY
Factor Details Relevance
Daycare Common exposure source for viral
Attends daycare?
attendance infections
