I HUMAN CASE STUDY WEEK 4 FOR AN 18- MONTH-OLD MALE (86 CM / 12.7 KG) — REASON FOR ENCOUNTER: COUGH (CLASS 6541) LATEST UPDATE

I HUMAN CASE STUDY WEEK 4 FOR AN 18-
MONTH-OLD MALE (86 CM / 12.7 KG) —
REASON FOR ENCOUNTER: COUGH (CLASS
6541) LATEST UPDATE




1. General Case Information g; g;




Case title & summary:
g; g; g;



18-month-old male with 4 days of cough, rhinorrhea, intermittent low-grade fever,
g; g; g; g; g; g; g; g; g; g;



and nocturnal worsening. Focus: differentiate viral URI, bronchiolitis, pneumonia,
g; g; g; g; g; g; g; g; g;



g; reactive airways, and foreign-body aspiration; assess need for ED management
g; g; g; g; g; g; g; g; g;



g; vs outpatient supportive care.
g; g; g;




Reason for encounter: g; g;



Parent reports persistent cough that disrupts sleep and reduces oral intake.
g; g; g; g; g; g; g; g; g; g;




Patient demographics: g;

, • Age: 18 months g; g;



• Sex: Male g;



• Height: 86 cm (2′10″) g; g; g;



• Weight: 12.7 kg (20 lb) g; g; g; g;



• Growth: Appears age-appropriate per parent report and prior well-
g; g; g; g; g; g; g; g;



child records g;




Case mode: Learning mode (Class 6541)
g; g; g; g; g;




Case location: Pediatric clinic with pulse oximetry, X-ray, and basic lab access
g; g; g; g; g; g; g; g; g; g; g;




Attempts allowed: Unlimited (learning)
g; g; g;




2. Chief Complaint (CC) g; g;




Parent: “My toddler has been coughing for four days and his sleep and eating are
g; g; g; g; g; g; g; g; g; g; g; g; g; g;



worse.”
g;




• Onset: 4 days ago g; g; g;



• Course: Gradually worse at night; occasionally “wet” sounding cough
g; g; g; g; g; g; g; g;



• Severity: Mild–moderate; causes awakenings and decreased appetite
g; g; g; g; g; g;



• Associated: Clear rhinorrhea, one day of low-grade fever (max ~37.9°C),
g; g; g; g; g; g; g; g; g;



no vomiting, no witnessed choking
g; g; g; g; g;




3. History of Present Illness (HPI)
g; g; g; g;

, • Cough began after rhinorrhea; initially intermittent dry cough, now
g; g; g; g; g; g; g; g;



g; more frequent and worse when supine.
g; g; g; g; g;



• No audible wheeze reported at home, but parent notes “breathing
g; g; g; g; g; g; g; g; g;



g; faster” with coughing episodes.
g; g; g;



• Drinks liquids but has eaten less solids for last 48 hours. Still has
g; g; g; g; g; g; g; g; g; g; g; g;



g; adequate wet diapers. g; g;



• Attends daycare; several classmates had colds in past 2 weeks.
g; g; g; g; g; g; g; g; g;



• No known TB exposure, no travel, no household smokers.
g; g; g; g; g; g; g; g;



• Immunizations reportedly up to date for age (including DTaP, Hib, g; g; g; g; g; g; g; g; g;



PCV, MMR per schedule).
g; g; g; g;



• No prior hospitalizations; one prior mild viral URI.
g; g; g; g; g; g; g;




4. Past Medical History (PMH)
g; g; g;




• Full-term birth, normal development. g; g; g;



• No history of prematurity, chronic lung disease, congenital heart disease,
g; g; g; g; g; g; g; g; g;



or recurrent severe respiratory infections.
g; g; g; g; g;



• No known food/drug allergies.
g; g; g;




5. Medications & Allergies g; g;




Current meds: Occasional acetaminophen given at home for fever.
g; g; g; g; g; g; g; g;



Allergies: None known. g; g;