,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 the past four days, and it’s
keeping her up at night."
, 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 four days. The mother describes the
cough as dry, non-productive, and worse at night, causing sleep
disruption. The cough is accompanied by a low-grade fever (maximum
100.4°F orally) for two days, which resolved with acetaminophen. The
mother reports mild nasal congestion and clear rhinorrhea but denies
vomiting, diarrhea, or ear pulling. Emma attends daycare three days a
week, where several children have had similar symptoms. There has
been no recent travel or known exposure to tuberculosis. Emma’s
appetite has decreased slightly, but she is drinking fluids normally. The
mother denies any history of wheezing, shortness of breath, or choking
episodes. No recent changes in medications or new environmental
exposures were reported.
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 the past four days, and it’s
keeping her up at night."
, 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 four days. The mother describes the
cough as dry, non-productive, and worse at night, causing sleep
disruption. The cough is accompanied by a low-grade fever (maximum
100.4°F orally) for two days, which resolved with acetaminophen. The
mother reports mild nasal congestion and clear rhinorrhea but denies
vomiting, diarrhea, or ear pulling. Emma attends daycare three days a
week, where several children have had similar symptoms. There has
been no recent travel or known exposure to tuberculosis. Emma’s
appetite has decreased slightly, but she is drinking fluids normally. The
mother denies any history of wheezing, shortness of breath, or choking
episodes. No recent changes in medications or new environmental
exposures were reported.
IV. Past Medical History (PMH)
