NR 602 Week 7 – iHuman Case 5: Michael
Martinez
Patient Name: Michael Martinez
Age: 18 months
Gender: Male
Chief Complaint: "He's been coughing and also has fever. He seems to be
getting sicker, so I thought I should have someone look at him." (mother)
I. History of Present Illness (HPI)
Michael is an 18-month-old male brought to the office by his mother with a
five-day history of progressive respiratory symptoms.
Timeline of Symptoms:
• Five days ago: Runny nose (rhinorrhea) began.
• Two nights ago: Cough developed; initially dry, but now productive of
small amounts of yellow sputum.
• Last 24–48 hours: Difficulty breathing has become more apparent;
mother reports he "just seems miserable." Cough worsens with activity
(e.g., running, playing hard).
• Appetite: Decreased over the past few days. He is eating less than usual
but still drinking and having 4–5 wet diapers per day (no decrease in
urine output).
• Fever: Present, treated with Tylenol (acetaminophen) 2–3 times daily.
Mother is unsure of the dose and uses a dropper, but Michael often spits
it out.
• No vomiting, diarrhea, or known ill contacts besides other children
at daycare who have been sick.
, Pertinent Negatives:
• No stridor, grunting, or apnea.
• No known allergies.
• No prescription medications.
• No previous history of wheezing or asthma diagnosed.
• No known underlying cardiac or pulmonary disease.
II. Review of Systems (ROS)
• Constitutional: Fever (up to 102°F), decreased energy, irritability.
• HEENT: Nasal congestion, rhinorrhea (thick yellow discharge), mild sore
throat.
• Respiratory: Cough (productive of yellow sputum), difficulty breathing,
nasal flaring, retractions (mother noticed "sucking in" around ribs/neck).
• Cardiovascular: No cyanosis, no chest pain.
• Gastrointestinal: Decreased appetite, no vomiting, no diarrhea.
• Genitourinary: 4–5 wet diapers/day (adequate urine output).
• Musculoskeletal: No swelling or limitation of movement.
• Neurological: Alert but fussy; no seizures or lethargy.
III. Past Medical, Family, and Social History
Past Medical History:
• Full-term vaginal delivery, no complications.
• Immunizations: Up-to-date per age.
• Previous illnesses: Mild colds over the past few months, but none as
severe as this episode.
• No hospitalizations or surgeries.
Family History:
• No known genetic conditions.
• No family history of asthma, atopy, or chronic lung disease.
Martinez
Patient Name: Michael Martinez
Age: 18 months
Gender: Male
Chief Complaint: "He's been coughing and also has fever. He seems to be
getting sicker, so I thought I should have someone look at him." (mother)
I. History of Present Illness (HPI)
Michael is an 18-month-old male brought to the office by his mother with a
five-day history of progressive respiratory symptoms.
Timeline of Symptoms:
• Five days ago: Runny nose (rhinorrhea) began.
• Two nights ago: Cough developed; initially dry, but now productive of
small amounts of yellow sputum.
• Last 24–48 hours: Difficulty breathing has become more apparent;
mother reports he "just seems miserable." Cough worsens with activity
(e.g., running, playing hard).
• Appetite: Decreased over the past few days. He is eating less than usual
but still drinking and having 4–5 wet diapers per day (no decrease in
urine output).
• Fever: Present, treated with Tylenol (acetaminophen) 2–3 times daily.
Mother is unsure of the dose and uses a dropper, but Michael often spits
it out.
• No vomiting, diarrhea, or known ill contacts besides other children
at daycare who have been sick.
, Pertinent Negatives:
• No stridor, grunting, or apnea.
• No known allergies.
• No prescription medications.
• No previous history of wheezing or asthma diagnosed.
• No known underlying cardiac or pulmonary disease.
II. Review of Systems (ROS)
• Constitutional: Fever (up to 102°F), decreased energy, irritability.
• HEENT: Nasal congestion, rhinorrhea (thick yellow discharge), mild sore
throat.
• Respiratory: Cough (productive of yellow sputum), difficulty breathing,
nasal flaring, retractions (mother noticed "sucking in" around ribs/neck).
• Cardiovascular: No cyanosis, no chest pain.
• Gastrointestinal: Decreased appetite, no vomiting, no diarrhea.
• Genitourinary: 4–5 wet diapers/day (adequate urine output).
• Musculoskeletal: No swelling or limitation of movement.
• Neurological: Alert but fussy; no seizures or lethargy.
III. Past Medical, Family, and Social History
Past Medical History:
• Full-term vaginal delivery, no complications.
• Immunizations: Up-to-date per age.
• Previous illnesses: Mild colds over the past few months, but none as
severe as this episode.
• No hospitalizations or surgeries.
Family History:
• No known genetic conditions.
• No family history of asthma, atopy, or chronic lung disease.
