iHUMAN 18monthOld COUGH
Green means good questions.
How can I help him today? He has been coughing and hasfever. He seemsto be getting sicker,
so I brought him in.
Does he have any other symptoms or concerns we should discuss? Yes, he has runny nose and
difficulty breathing. He hasn’t been his usual self since this started.
Is he taking any prescription medications? No nothing prescription maybe he needssomething
though.
Is he taking any medications for hissymptoms? Yes I’ve been giving him Tylenol.
Does he have any pain anywhere? No not that I have noticed.
When did his cough start? 2 nights ago
When did his difficulty breathing start? I first noticed it with his runny nose that started 5 days
ago. It has gotten worse since his cough started.
Does anything make his cough better or worse? Being active makes his cough worse, especially
when he is running and playing.
Is he coughing up any sputum? Yes a little bit.
What does his sputum look like? Yellow
What treatment has he had for his fever? Tylenol about 2-3 times per day. I can’t remember
the amount. I always have to check the box to figure out, so I don’t know how much he is really
getting. I haven’t tried cool cloths or anything like that.
Is he exposed to secondhand smoke? Yes his dad smokes at home.
Has he had any contact with other sick people? I know some kids at his daycare have been sick
Does he have any allergies? None that we know of.
Has he had any changes in his appetite? He has not been as hungry the past few days. He is
eating but less than normal. He seems to be drinking normally.
How many wet diapers does he make a day? 4-5
HPI
CC: cough
HPI: Grady is an 18-month-old African American male who presents with productive cough,
small amount of yellow sputum, worsening difficulty breathing, and fever for two days. His RR is
labored at 40 and O2 sats are 92%. He began with a runny nose and difficulty breathing 5 days
ago. He goes to daycare where other children are known to be be sick recently. He has
secondhand smoke exposure from dad smoking in home. There is a family history of seasonal
allergies. Mom has only given him Tylenol for fever and tried a humidifier in his room.
ROS
Genera: alert, febrile at home, not himself.