Jake Mason is an 18-month-old male presenting with a chief complaint of “cough and difficulty breathing” brought to urgent care by his father. The toddler has been experiencing worsening respiratory symptoms, including a productive cough worse at night, fever, and decreased appetite over the past 2-3 days.
In this comprehensive guide, we’ll walk you through how to approach his case, from initial history-taking through physical examination to the final diagnosis of pneumonia and respiratory management. You’ll learn the key clinical reasoning steps specific to pediatric respiratory cases, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this challenging pediatric simulation.
Jake Mason iHuman Case Overview (Doorway Information)
Patient Overview: Jake Mason is an 18-month-old male presenting with a chief complaint of “cough and difficulty breathing” that has been worsening over the past 2-3 days. His father reports that Jake has been having a productive cough that is significantly worse at night, accompanied by fever and decreased appetite. The child has been exposed to secondhand smoke and sick children at daycare.
Key Background Information:
- Age/Gender: 18-month-old male
- Chief Complaint: Cough and difficulty breathing
- Duration: 2-3 days of worsening symptoms
- Cough Characteristics: Productive with yellow sputum, worse at night
- Associated Symptoms: Fever, rhinorrhea, decreased appetite
- Environmental Exposures: Secondhand smoke, sick children at daycare
- Presenting Concerns: Respiratory distress, intercostal retractions, fine crackles
- Current Status: Brought to urgent care by father for evaluation
The patient appears ill and in mild respiratory distress with visible work of breathing. His presentation is classic for pediatric lower respiratory tract infection, making this an excellent case for learning systematic pediatric respiratory assessment and age-specific management strategies.
Jake Mason iHuman (18 months old male) – Respiratory Assessment
- CC: Cough and difficulty breathing
- MSAP: Productive cough worse at night with yellow sputum, fever, respiratory distress with intercostal retractions
- Associated symptoms: Rhinorrhea, decreased appetite, exposure to secondhand smoke
- Environmental factors: Daycare exposure to sick children, secondhand smoke exposure
- Respiratory distress indicators: Fine crackles, intercostal retractions, increased work of breathing
History Questions:
- How can I help you today?
- When did you first notice Jake having trouble breathing?
- Can you describe his cough? (dry, wet, barking, honking)
- Has he been producing any sputum? What color?
- Is the cough worse at any particular time of day?
- Has he had a fever? How high?
- How has his appetite been?
- Has he been drinking fluids normally?
- Any changes in his activity level or playfulness?
- Has he been exposed to anyone who’s been sick?
- Does anyone in the household smoke?
- What is his vaccination status?
- Has he had any similar episodes before?
- Any family history of asthma or respiratory problems?
- Has he been to daycare recently?
- Any known allergies?
- Is he taking any medications?
- Any recent travel?
- How has his sleep been affected?
- Any difficulty feeding or taking bottles?
- Have you noticed any color changes around his mouth or fingernails?
- Any unusual breathing patterns or sounds?
Physical Exam:
- Vitals: temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
- General appearance: level of distress, activity level, alertness
- Skin: color, temperature, capillary refill
- HEENT:
- Examine the ears, nose, and throat
- Look for signs of upper respiratory infection
- Check for nasal congestion/discharge
- Neck: lymph nodes, any swelling
- Chest wall & lungs:
- Visual inspection for retractions, use of accessory muscles
- Palpate chest for tenderness, expansion
- Percuss the lung fields
- Auscultate all lung fields systematically
- Heart:
- Auscultate for murmurs, rate, rhythm
- Check for signs of cardiac stress
- Abdomen:
- Inspect, auscultate, palpate
- Check for hepatomegaly
- Extremities:
- Check perfusion, clubbing, cyanosis
- Assess muscle tone and reflexes
Assessment Note:
J.M. is an 18-month-old male presenting with 2-3 day history of worsening productive cough, fever, and respiratory distress. Physical exam notable for intercostal retractions, fine crackles on auscultation, and mild tachypnea. Environmental exposures include secondhand smoke and recent daycare attendance with exposure to sick children. Clinical presentation consistent with community-acquired pneumonia.
Likely Diagnosis: Community-acquired pneumonia Supporting Evidence: Productive cough with purulent sputum, fever, respiratory distress, fine crackles, age-appropriate risk factors
Jake Mason iHuman Plan:
- Immediate Management:
- Oxygen saturation monitoring
- Supplemental oxygen if SpO2 < 92%
- Elevate the head of the bed
- Humidified oxygen therapy
- Diagnostic Testing:
- Chest X-ray to confirm diagnosis
- Complete blood count with differential
- Blood cultures if severely ill
- Rapid viral panel (RSV, influenza)
- Sputum culture (if obtainable)
- Pharmacological Treatment:
- Age-appropriate antibiotic therapy (amoxicillin first-line)
- Fever management with acetaminophen or ibuprofen
- Consider a bronchodilator trial if wheezing is present
- Supportive Care:
- Encourage fluid intake
- Rest and activity as tolerated
- Humidification
- Close monitoring of respiratory status
- Education and Follow-up:
- Return precautions for parents
- Follow-up in 24-48 hours
- Complete the antibiotic course
- Smoking cessation counseling for the household
Jake Mason SOAP Note
Patient: Jake Mason Subjective Data
CC: 18-month-old male brought by father with “cough and difficulty breathing”
HPI: Jake Mason is an 18-month-old male who presents to urgent care with a 2-3 day history of worsening cough and respiratory symptoms. The father reports that Jake initially had what seemed like a cold with a runny nose and low-grade fever, but over the past two days has developed a productive cough that is significantly worse at night. The cough produces yellow-colored sputum. Jake has had a decreased appetite and has been less active than usual. Father notes that Jake seems to be working harder to breathe and has been more irritable, especially at night. The child attends daycare where several children have been sick with similar symptoms. There is secondhand smoke exposure in the home from the father’s smoking.
Medications: None currently. Acetaminophen as needed for fever.
Allergies: No known drug allergies
PMH: Full-term delivery, no complications. Up to date on vaccinations, including pneumococcal conjugate vaccine.
Family History: No significant family history of respiratory or cardiac disease. Father smokes cigarettes.
Social History: Lives with father and paternal grandmother. Attends daycare 4 days per week. Recently exposed to multiple sick children at daycare.
Environmental: Secondhand smoke exposure from the father’s cigarette use inside the home.
Objective Data
ROS:
- General: Decreased activity level, irritability, decreased appetite, fever
- HEENT: Rhinorrhea with clear to yellow discharge, no ear pain reported
- Respiratory: Productive cough worse at night, mild respiratory distress
- Cardiovascular: No known heart problems
- GI: Decreased appetite, normal bowel movements, adequate fluid intake
- GU: Normal urination pattern
- Neurologic: Alert but somewhat irritable, normal development for age
Vital Signs:
- Temperature: 101.2°F (38.4°C)
- Heart Rate: 125 bpm
- Respiratory Rate: 32 breaths/min
- Blood Pressure: 95/60 mmHg
- Oxygen Saturation: 94% on room air
- Weight: 24 lbs (10.9 kg)
Assessment
General: 18-month-old male appears mildly ill, alert but somewhat irritable. Mild respiratory distress with increased work of breathing.
Vital Signs: Febrile, mild tachypnea, oxygen saturation borderline low for age.
HEENT: Nasal congestion with yellow rhinorrhea. Throat without erythema or exudate. Tympanic membranes are clear bilaterally.
Respiratory: Mild intercostal retractions noted. Fine crackles were heard in the bilateral lower lung fields. No wheezing. Equal chest expansion.
Cardiovascular: Regular rate and rhythm, no murmurs. Capillary refill < 3 seconds.
Abdomen: Soft, non-tender, bowel sounds present. No hepatomegaly.
Extremities: Warm, well-perfused. No clubbing or cyanosis.
Skin: Warm and dry, appropriate color for ethnicity.
Differential Diagnoses
Community-Acquired Pneumonia: Most likely diagnosis given productive cough with purulent sputum, fever, fine crackles on auscultation, and mild respiratory distress. Age and daycare exposure are consistent risk factors.
Viral Upper Respiratory Infection: Could present with cough and rhinorrhea, but is less likely to cause significant respiratory distress and fine crackles. Usually self-limiting.
Bronchiolitis: Common in this age group, especially with RSV. However, typically presents with wheezing and more significant respiratory distress.
Asthma Exacerbation: Could cause cough and respiratory symptoms, but is usually associated with wheezing and a family history. No previous episodes reported.
Most Likely Diagnosis: Community-acquired pneumonia evidenced by productive cough with purulent sputum, fever, fine crackles on auscultation, mild respiratory distress, and appropriate epidemiologic risk factors.
Complete Step-by-Step Guide to Writing the Jake Mason iHuman Case Study
Step 1: Pre-Case Preparation and Pediatric Considerations
Key Pediatric Factors to Remember:
- Age-specific normal vital signs (18-month-old: HR 80-130, RR 20-30, BP varies)
- Developmental considerations for assessment
- Age-appropriate communication with the caregiver
- Vaccination status relevance
- Environmental exposure importance
Initial Clinical Mindset: Approach with pediatric respiratory conditions as the primary consideration. Age makes viral and bacterial respiratory infections most likely, with pneumonia being a significant concern given symptom severity.
Step 2: Conducting Pediatric History of Present Illness (HPI)
Use the OLDCARTS method while considering pediatric-specific factors:
Onset: When did symptoms start, and how did they progress
- Key finding: Started 2-3 days ago as “cold” symptoms, worsened to respiratory distress
Location: Where are the symptoms (chest, throat, nose)
- Target response: Productive cough from chest, nasal congestion
Duration: How long do coughing episodes last
- Important detail: Persistent cough, worse at night, disrupting sleep
Character: Description of cough quality and sputum
- Critical descriptor: Productive cough with yellow sputum
Aggravating factors: What makes symptoms worse
- Essential findings: Night time, lying flat, activity
Relieving factors: What provides relief
- Key response: Sitting upright, rest, humidified air
Timing: Pattern of symptoms
- Important pattern: Progressive worsening, nocturnal exacerbation
Severity: Impact on function
- Pediatric consideration: Decreased activity, poor feeding, sleep disruption
Step 3: Pediatric Review of Systems (ROS)
General: Energy level, appetite changes, sleep disturbances, fever patterns
Respiratory:
- Work of breathing changes
- Cough character and timing
- Sputum production
- Breathing difficulty with activity
Cardiovascular:
- Feeding tolerance (important in infants/toddlers)
- Activity level changes
- Color changes
GI: Appetite changes, vomiting, feeding difficulties
Infectious: Fever patterns, exposures, vaccination status
Step 4: Environmental and Social History
Daycare/School Exposures:
- Recent sick contacts
- Outbreak information
- Vaccination compliance
Home Environment:
- Smoking exposure (critical risk factor)
- Air quality factors
- Household illness
Developmental History:
- Meeting milestones
- Previous respiratory illnesses
- Feeding and growth patterns
Step 5: Pediatric Physical Examination Strategy
Approach Considerations:
- Examine the child on the parent’s lap if possible
- Least invasive procedures first
- Use distraction techniques
- Age-appropriate equipment
Respiratory Focus:
- Observe the work of breathing before touching the child
- Count the respiratory rate for a full minute
- Look for retractions, nasal flaring, and head bobbing
- Auscultate systematically with a pediatric stethoscope
- Assess oxygen saturation
Expected Findings:
- Mild tachypnea (RR 28-35 for age)
- Fine crackles in affected areas
- Possible intercostal retractions
- Fever
- Oxygen saturation 92-94%
Step 6: Developing Pediatric Differential Diagnoses
Primary Considerations:
Community-Acquired Pneumonia
- Supporting evidence: Age, daycare exposure, productive cough, fever, crackles
- Most common bacterial: Streptococcus pneumoniae
Viral Respiratory Infection
- Supporting evidence: Season, daycare exposure, gradual onset
- Consider: RSV, rhinovirus, influenza
Bronchiolitis
- Supporting evidence: Age group, viral prodrome
- Expected: Wheezing, more severe distress
Step 7: Diagnostic Test Interpretation
Expected Key Tests:
- Chest X-ray: May show consolidation or infiltrates
- CBC: Possible leukocytosis with bacterial infection
- Rapid viral panel: Rule out RSV, influenza
- Oxygen saturation: Monitor respiratory status
- Blood cultures: If severely ill or hospitalized
Step 8: Pediatric-Specific Diagnosis and Management
Primary Diagnosis: Community-acquired pneumonia
Justification:
- Age-appropriate presentation
- Classic symptom progression
- Physical exam findings are consistent
- Risk factors present (daycare, smoke exposure)
Step 9: Comprehensive Pediatric Management Plan
Immediate Assessment:
- Severity stratification
- Need for hospitalization vs outpatient management
- Respiratory support requirements
Pharmacological Management:
- First-line antibiotic: Amoxicillin 90 mg/kg/day divided twice daily
- Alternative: Amoxicillin-clavulanate if atypical bacteria are suspected
- Fever management: Acetaminophen 15 mg/kg every 4-6 hours or ibuprofen 10 mg/kg every 6-8 hours
Supportive Care:
- Humidified air
- Adequate hydration
- Rest with activity as tolerated
- Oxygen supplementation if SpO2 < 92%
Monitoring:
- Daily assessment for the first 2-3 days
- Return precautions for worsening
- Complete the antibiotic course
Prevention:
- Smoking cessation counseling for the family
- Hand hygiene education
- Vaccination compliance
Step 10: Pediatric Documentation and Safety
Key Safety Considerations:
- Clear return precautions for parents
- Signs of respiratory distress requiring immediate care
- Medication dosing safety
- Follow-up scheduling
Parent Education Topics:
- Expected course of illness
- Medication administration
- When to seek immediate care
- Environmental modifications
Jake Mason iHuman Case Summary
Grading Criteria for Pediatric Cases:
(1) History Taking (Major Points): Focus on age-appropriate questioning and caregiver interview skills. Essential questions include the onset and progression of symptoms, cough characteristics, fever patterns, changes in feeding and activity, exposure history (including daycare and smoking), and vaccination status. The rubric rewards students who ask about environmental exposures and developmental considerations specific to pediatric patients.
(2) Physical Examination (High Weight): Pediatric-focused examination with age-appropriate techniques. Must-do components: vital signs with age-specific norms, respiratory assessment including work of breathing, auscultation technique for toddlers, and assessment of hydration status. Pro tip: The rubric awards points for observing the child before examination and using appropriate restraint/comfort techniques.
(3) Differential Diagnosis (Critical for Scoring): Age-appropriate differentials with understanding of pediatric disease patterns. Expected differentials: community-acquired pneumonia, viral respiratory infection, bronchiolitis. Scoring secret: Understanding age-specific epidemiology and risk factors.
(4) Final Diagnosis & MSAP: Must correctly identify pneumonia with supporting evidence and age-appropriate reasoning.
(5) Management Plan (Heavily Weighted): Pediatric-specific treatment including weight-based medication dosing, supportive care measures, and family education. High-scoring responses include: appropriate antibiotic selection and dosing, symptom management, follow-up planning, and prevention strategies.
(6) Family Communication: Demonstrate clear communication with caregivers, including return precautions and expectations for recovery.
Jake Mason Clinical Summary Example
Patient Summary – Jake Mason
Situation: 18-month-old male presenting with 2-3 day history of productive cough, fever, and mild respiratory distress.
Background: Healthy toddler with daycare exposure to ill children and household secondhand smoke exposure. Up-to-date on immunizations, including pneumococcal vaccine.
Assessment: Physical examination notable for fever (101.2°F), mild tachypnea (RR 32), oxygen saturation 94%, fine crackles bilateral lower lobes, and mild intercostal retractions. No signs of severe respiratory distress.
Primary Diagnosis: Community-acquired pneumonia, mild severity, suitable for outpatient management.
Recommendation:
- Amoxicillin 90 mg/kg/day divided BID x 10 days
- Supportive care with humidification and adequate hydration
- Acetaminophen for fever management
- Close follow-up in 24-48 hours
- Return the precautions provided to the father
- Smoking cessation counseling for household members
Patient/Family Education: Explained pneumonia in age-appropriate terms for the caregiver, emphasized the importance of medication compliance, provided clear return precautions for worsening respiratory distress, and discussed environmental modifications to reduce future risk.
Key Success Factors for Jake Mason Case
Pediatric-Specific Considerations:
- Understand normal vital signs for an 18-month-old
- Recognize age-appropriate disease patterns
- Use proper examination techniques for toddlers
- Calculate weight-based medication dosing
- Provide appropriate caregiver education
Clinical Reasoning Focus:
- Systematic approach to pediatric respiratory distress
- Integration of environmental and social factors
- Age-appropriate differential diagnosis
- Evidence-based treatment decisions
- Family-centered care approach
Common Pitfalls to Avoid:
- Using adult normal values for vital signs
- Inadequate assessment of work of breathing
- Missing environmental risk factors
- Inappropriate antibiotic dosing
- Insufficient parent education
Frequently Asked Questions
Q1: What is the most likely diagnosis for Jake Mason’s respiratory symptoms?
Community-acquired pneumonia is the most likely diagnosis based on his productive cough with purulent sputum, fever, fine crackles on examination, and mild respiratory distress. The combination of daycare exposure and secondhand smoke creates an appropriate risk factor for bacterial pneumonia in this age group.
Q2: What are the critical physical exam components for scoring well in pediatric respiratory cases?
Essential components include observing work of breathing before touching the child, obtaining accurate vital signs with age-appropriate norms, systematic respiratory auscultation, assessment for retractions and accessory muscle use, and evaluation of hydration status. Don’t forget to assess oxygen saturation, the overall appearance of illness.
Q3: How do I determine if this case requires hospitalization vs outpatient management?
Outpatient management is appropriate for this case based on: age > 3 months, ability to maintain oral intake, oxygen saturation > 92%, mild respiratory distress without severe retractions, and reliable caregivers for follow-up. Hospitalization would be considered for severe respiratory distress, poor oral intake, or social concerns.
Q4: What is the appropriate antibiotic choice and dosing for pediatric pneumonia?
First-line treatment is amoxicillin 90 mg/kg/day divided twice daily for 10 days. This high-dose amoxicillin covers the most common bacterial pathogen (Streptococcus pneumoniae), including some resistant strains. Alternative options include amoxicillin-clavulanate for broader coverage or macrolides if atypical bacteria are suspected.