NR 602 Week 7 – iHuman Case 5: Michael
Martinez
with fever, cough, runny nose, difficulty
breathing, and reduced appetite
Patient Name: Michael Martinez
Age: 18 months
Sex: Male
Chief Complaint (mother): "He’s been pulling at his ear and crying a lot. He
had a cold last week, and now he has a fever again."
Case,
NR 602 Week 7 – iHuman Case 5 Michael Martinez (18-month-old child)
Introduction: This document provides the full iHuman case for Michael Martinez,
an 1 8-month-old child presenting with fever, cough, runny nose, difficulty
breathing, and reduced appetite. It includes history of present illness, review of
systems, physical exam findings, problem statement, diagnostics, and SOAP plan.
The case highlights RSV bronchiolitis, secondhand smoke exposure, and
recommended management, including emergency referral and supportive care.
This is a complete case study aligned with NR 602 coursework.
I. History of Present Illness (HPI)
Michael is an 18-month-old male brought to the clinic by his mother.
Approximately 7 days ago, he developed a mild runny nose and occasional
cough, which the mother attributed to a “common cold.” Over the past 2 days,
the cough has become more frequent (non-productive) and the mother noted
that Michael has been fussy, tugging at his left ear, and waking up multiple
times at night. He had a low-grade fever (100.5°F) yesterday but today it rose
to 102.5°F (tympanic). The mother gave acetaminophen this morning, which
temporarily reduced the fever and fussiness.
• Ear pulling: Mother reports he repeatedly pulls or rubs his left ear,
especially during feeds or when lying down.
• Cough: Dry, hacking cough, worse at night and with activity.
, • Appetite/fluids: Decreased appetite; he refuses solid foods but takes
small amounts of formula and water. Wet diapers: 3 in the past 24 hours
(down from his usual 5–6).
• No vomiting, diarrhea, or rash.
• No known ill contacts besides the prior cold symptoms in the
household (mother also had a mild URI last week).
• No previous ear infections – this is his first episode.
Pertinent Negatives:
• No difficulty breathing, no wheezing, no stridor.
• No drainage from the ear (no otorrhea).
• No known allergies to medications.
• No previous antibiotic use.
II. Review of Systems (ROS)
• Constitutional: Fever, fussiness, decreased energy.
• HEENT: Nasal congestion (mild, clear discharge), ear pulling (left), no
reported hearing loss.
• Respiratory: Dry cough, no difficulty breathing.
• Cardiovascular: No cyanosis or chest pain.
• Gastrointestinal: Decreased appetite, no vomiting/diarrhea.
• Genitourinary: 3 wet diapers in 24 hours (mild dehydration).
• Neurological: Irritable but consolable; no lethargy or seizures.
III. Past Medical, Family, and Social History
(Identical to previous case, but with added note about no prior ear infections)
Past Medical History:
• Full-term vaginal delivery, no complications.
• Immunizations: Up-to-date, including PCV13 (Prevenar) and Hib.
• Previous illnesses: Mild colds; no prior acute otitis media.
• No hospitalizations.
Family History:
• No significant atopy or recurrent OM in parents/siblings.
Social History:
Martinez
with fever, cough, runny nose, difficulty
breathing, and reduced appetite
Patient Name: Michael Martinez
Age: 18 months
Sex: Male
Chief Complaint (mother): "He’s been pulling at his ear and crying a lot. He
had a cold last week, and now he has a fever again."
Case,
NR 602 Week 7 – iHuman Case 5 Michael Martinez (18-month-old child)
Introduction: This document provides the full iHuman case for Michael Martinez,
an 1 8-month-old child presenting with fever, cough, runny nose, difficulty
breathing, and reduced appetite. It includes history of present illness, review of
systems, physical exam findings, problem statement, diagnostics, and SOAP plan.
The case highlights RSV bronchiolitis, secondhand smoke exposure, and
recommended management, including emergency referral and supportive care.
This is a complete case study aligned with NR 602 coursework.
I. History of Present Illness (HPI)
Michael is an 18-month-old male brought to the clinic by his mother.
Approximately 7 days ago, he developed a mild runny nose and occasional
cough, which the mother attributed to a “common cold.” Over the past 2 days,
the cough has become more frequent (non-productive) and the mother noted
that Michael has been fussy, tugging at his left ear, and waking up multiple
times at night. He had a low-grade fever (100.5°F) yesterday but today it rose
to 102.5°F (tympanic). The mother gave acetaminophen this morning, which
temporarily reduced the fever and fussiness.
• Ear pulling: Mother reports he repeatedly pulls or rubs his left ear,
especially during feeds or when lying down.
• Cough: Dry, hacking cough, worse at night and with activity.
, • Appetite/fluids: Decreased appetite; he refuses solid foods but takes
small amounts of formula and water. Wet diapers: 3 in the past 24 hours
(down from his usual 5–6).
• No vomiting, diarrhea, or rash.
• No known ill contacts besides the prior cold symptoms in the
household (mother also had a mild URI last week).
• No previous ear infections – this is his first episode.
Pertinent Negatives:
• No difficulty breathing, no wheezing, no stridor.
• No drainage from the ear (no otorrhea).
• No known allergies to medications.
• No previous antibiotic use.
II. Review of Systems (ROS)
• Constitutional: Fever, fussiness, decreased energy.
• HEENT: Nasal congestion (mild, clear discharge), ear pulling (left), no
reported hearing loss.
• Respiratory: Dry cough, no difficulty breathing.
• Cardiovascular: No cyanosis or chest pain.
• Gastrointestinal: Decreased appetite, no vomiting/diarrhea.
• Genitourinary: 3 wet diapers in 24 hours (mild dehydration).
• Neurological: Irritable but consolable; no lethargy or seizures.
III. Past Medical, Family, and Social History
(Identical to previous case, but with added note about no prior ear infections)
Past Medical History:
• Full-term vaginal delivery, no complications.
• Immunizations: Up-to-date, including PCV13 (Prevenar) and Hib.
• Previous illnesses: Mild colds; no prior acute otitis media.
• No hospitalizations.
Family History:
• No significant atopy or recurrent OM in parents/siblings.
Social History:
