PEDIATRIC COUGH CASE FULL SOAP NOTE AND FOLLOW-
UP PLAN BY I-HUMAN PATIENTS ACADEMIC TEAM WITH
COMPLETE ANSWERS LATEST 2025-2026 EDITION
GUARANTEED EXAM 100% PASS
, 1. Case Overview
This case involves an 18-month-old male toddler presenting with cough, a very common pediatric
complaint. The goal is to differentiate between benign viral illness and more serious respiratory
conditions, while demonstrating safe pediatric assessment, caregiver communication, and appropriate
management.
This scenario tests your ability to:
• Take a focused pediatric history from a caregiver
• Identify red flags in respiratory illness
• Perform a targeted physical exam
• Develop a safe, evidence-based plan
2. Patient Profile
• Name: Grady Turner
• Age: 18 months
• Gender: Male
• Informant: Parent (mother)
• Chief Complaint: “He has been coughing for a few days.”
3. History of Present Illness (HPI)
Grady is an 18-month-old toddler with a 3–5-day history of cough, described as:
• Dry initially, now occasionally productive
• Worse at night
• Associated with mild nasal congestion
Additional findings:
• Low-grade fever (~37.8–38.2°C)
• Reduced appetite but still drinking fluids
• Normal urine output