iHuman toddler cough case study featuring an 18-month-old male with viral URI and bronchiolitis evaluation, diagnostic tests, SOAP notes, and follow-up care

iHuman toddler cough case study
featuring an 18-month-old male with
viral URI and bronchiolitis evaluation,
diagnostic tests, SOAP notes, and
follow-up care




Patient Case Analysis
1. Patient Information
Name: Michael Martinez
Age: 18 months
Sex: Male
Height: 86 cm
Weight: 12.7 kg (28 lb)

Chief Complaint:
“Cough.”

,2. History Questions (Important Questions to
Ask)
History of Present Illness (HPI)
 When did the cough begin?
 Was the onset sudden or gradual?
 Is the cough dry or productive?
 Is the cough worse at night?
 Does the child cough more during feeding or activity?
 Any barking or seal-like cough?
 Any wheezing or noisy breathing?
 Any episodes of choking?
 Has the cough improved or worsened?
 Any fever associated with the cough?
 Any shortness of breath?
 Any nasal congestion or runny nose?
 Any vomiting after coughing?
 Any cyanosis or bluish discoloration?

Associated Symptoms
 Fever
 Irritability
 Poor feeding
 Lethargy
 Sleep disturbance
 Ear pulling
 Sore throat
 Rash
 Vomiting
 Diarrhea

Respiratory History
 Previous respiratory infections
 History of asthma or wheezing
 Prior bronchiolitis
 Hospitalizations
 Exposure to cigarette smoke

Birth / Developmental History

,  Full-term or premature birth
 NICU admission history
 Vaccination status
 Developmental milestones

Exposure History
 Sick contacts at daycare
 Recent travel
 COVID or flu exposure
 Exposure to pets
 Exposure to allergens

Family History
 Asthma
 Allergies
 Eczema
 Respiratory diseases

Medication History
 Current medications
 Recent antibiotics
 Use of cough syrup
 Nebulizer treatments




3. Physical Examination
General Appearance
 Alert toddler
 Mild respiratory discomfort possible
 Observe activity level and interaction

Vital Signs
 Temperature
 Heart rate
 Respiratory rate
 Oxygen saturation