,Patient Information
Name: Emma Carter
Age: 18 months
Gender: Female
Ethnicity: Hispanic
Setting: Outpatient pediatric clinic with access to laboratory and
imaging capabilities
Date of Encounter: July 16, 2025
Informant: Mother
II. Chief Complaint (CC)
"My daughter has been coughing for three days and seems to be
breathing faster than usual."
, III. History of Present Illness (HPI)Emma Carter, an 18-month-old
Hispanic female, presents to the clinic accompanied by her mother with
a chief complaint of a cough for three days. The mother describes the
cough as dry, hacking, and worse at night, occurring frequently enough
to disrupt Emma’s sleep. Over the past 24 hours, the mother has
noticed Emma breathing faster than usual and appearing more irritable.
The mother reports a low-grade fever (maximum 100.4°F, measured at
home) that started two days ago, relieved with acetaminophen. Emma
has had a decreased appetite and reduced fluid intake but no vomiting
or diarrhea. The mother denies any choking episodes, foreign body
aspiration, or recent travel. Emma attends daycare three days a week,
where other children have had similar symptoms. There is no history of
wheezing, stridor, or cyanosis. Emma’s mother denies any recent
weight loss, night sweats, or prolonged symptoms.
IV. Past Medical History (PMH)
Name: Emma Carter
Age: 18 months
Gender: Female
Ethnicity: Hispanic
Setting: Outpatient pediatric clinic with access to laboratory and
imaging capabilities
Date of Encounter: July 16, 2025
Informant: Mother
II. Chief Complaint (CC)
"My daughter has been coughing for three days and seems to be
breathing faster than usual."
, III. History of Present Illness (HPI)Emma Carter, an 18-month-old
Hispanic female, presents to the clinic accompanied by her mother with
a chief complaint of a cough for three days. The mother describes the
cough as dry, hacking, and worse at night, occurring frequently enough
to disrupt Emma’s sleep. Over the past 24 hours, the mother has
noticed Emma breathing faster than usual and appearing more irritable.
The mother reports a low-grade fever (maximum 100.4°F, measured at
home) that started two days ago, relieved with acetaminophen. Emma
has had a decreased appetite and reduced fluid intake but no vomiting
or diarrhea. The mother denies any choking episodes, foreign body
aspiration, or recent travel. Emma attends daycare three days a week,
where other children have had similar symptoms. There is no history of
wheezing, stridor, or cyanosis. Emma’s mother denies any recent
weight loss, night sweats, or prolonged symptoms.
IV. Past Medical History (PMH)
