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# SECTION 1: SUBJECTIVE DATA (History of Present Illness)
## Chief Complaint (CC)
"Grady has had a cough for three days. He sounds congested and is
not eating well."
## Patient Profile
- **Name:** Grady Turner
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- **Age:** 18 months (15.5 kg, 50th percentile for weight; 82 cm,
50th percentile for height)
- **Sex:** Male
- **Race/Ethnicity:** Caucasian
- **Source of history:** Mother (reliable)
- **Date of encounter:** [current date]
## History of Present Illness (HPI)
Grady is an 18-month-old previously healthy male who developed
**cough, nasal congestion, and low-grade fever** approximately 3 days
ago. Mother reports the cough started as "occasional" but has become
**more frequent and worse at night**. Over the past 24 hours, the cough
is described as **"barking" or "seal-like"** and occurs in episodes
lasting 5-10 minutes. Mother notes **worsening with crying,
excitement, or lying down**.
**Onset:** 3 days ago, acute.
**Location:** Respiratory – no foreign body aspiration witnessed.
**Duration:** Persistent, worse at night (q2-3 hours).
**Character:** Barking cough, inspiratory stridor noted by mother
"a high-pitched sound when he breathes in after coughing."
**Aggravating factors:** Lying supine, crying, excitement, cold
air (when taken outside).
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**Relieving factors:** Being held upright, cool mist humidifier
(some relief), no improvement with over-the-counter cough syrup
(mother gave honey 1 tsp – no change).
**Timing:** Symptoms started with rhinorrhea and low-grade
fever (100.5°F max) first 2 days; fever resolved yesterday but cough
worsened.
**Severity:** Mother rates 7/10 (distressing); child has had **one
episode of post-tussive emesis** (vomited after coughing fit yesterday).
No cyanosis, no apneic spells.
### Associated Symptoms (ROS positive)
- **Fever:** 100.5°F (axillary) day 1 and 2; afebrile last 24 hours.
- **Rhinorrhea:** Clear to white nasal discharge.
- **Decreased appetite:** Taking only 50-60% of normal
formula/food intake.
- **Decreased activity:** More tired than usual, but still playing
intermittently.
- **No** difficulty breathing at rest (mother denies chest
retractions or nasal flaring).
- **No** stridor at rest – only with agitation or crying.
- **No** drooling, no toxic appearance.
- **No** known sick contacts – but older sibling (4 years) had
"cold" last week with cough, now resolved.
# SECTION 1: SUBJECTIVE DATA (History of Present Illness)
## Chief Complaint (CC)
"Grady has had a cough for three days. He sounds congested and is
not eating well."
## Patient Profile
- **Name:** Grady Turner
,2|Page
- **Age:** 18 months (15.5 kg, 50th percentile for weight; 82 cm,
50th percentile for height)
- **Sex:** Male
- **Race/Ethnicity:** Caucasian
- **Source of history:** Mother (reliable)
- **Date of encounter:** [current date]
## History of Present Illness (HPI)
Grady is an 18-month-old previously healthy male who developed
**cough, nasal congestion, and low-grade fever** approximately 3 days
ago. Mother reports the cough started as "occasional" but has become
**more frequent and worse at night**. Over the past 24 hours, the cough
is described as **"barking" or "seal-like"** and occurs in episodes
lasting 5-10 minutes. Mother notes **worsening with crying,
excitement, or lying down**.
**Onset:** 3 days ago, acute.
**Location:** Respiratory – no foreign body aspiration witnessed.
**Duration:** Persistent, worse at night (q2-3 hours).
**Character:** Barking cough, inspiratory stridor noted by mother
"a high-pitched sound when he breathes in after coughing."
**Aggravating factors:** Lying supine, crying, excitement, cold
air (when taken outside).
, 3|Page
**Relieving factors:** Being held upright, cool mist humidifier
(some relief), no improvement with over-the-counter cough syrup
(mother gave honey 1 tsp – no change).
**Timing:** Symptoms started with rhinorrhea and low-grade
fever (100.5°F max) first 2 days; fever resolved yesterday but cough
worsened.
**Severity:** Mother rates 7/10 (distressing); child has had **one
episode of post-tussive emesis** (vomited after coughing fit yesterday).
No cyanosis, no apneic spells.
### Associated Symptoms (ROS positive)
- **Fever:** 100.5°F (axillary) day 1 and 2; afebrile last 24 hours.
- **Rhinorrhea:** Clear to white nasal discharge.
- **Decreased appetite:** Taking only 50-60% of normal
formula/food intake.
- **Decreased activity:** More tired than usual, but still playing
intermittently.
- **No** difficulty breathing at rest (mother denies chest
retractions or nasal flaring).
- **No** stridor at rest – only with agitation or crying.
- **No** drooling, no toxic appearance.
- **No** known sick contacts – but older sibling (4 years) had
"cold" last week with cough, now resolved.
