I-Human Case Study (NEW): Chana Kumar | 86-Year-Old
Female With Fatigue, Comprehensive SOAP Note,
Assessment, and Care Plan
I-Human case study of Chana Kumar, an 86-year-old female presenting with fatigue. Includes a detailed SOAP
note, geriatric assessment, differential diagnoses, and evidence-based nursing and medical care plan for healthcare
students.
• I-Human case study Chana Kumar
• Chana Kumar I-Human
• I-Human fatigue case study
Patient Information
• Name: Chana Kumar
• Age: 86 years
• Sex: Female
• Date: [Simulation Date]
• Setting: Primary Care / Geriatric Clinic
• Source of History: Patient and daughter (reliable)
S – Subjective
Chief Complaint (CC):
“I feel tired all the time.”
,History of Present Illness (HPI):
Chana Kumar is an 86-year-old female who presents with progressive fatigue over the past 3–4 months. The patient
reports feeling exhausted even after minimal activity, such as walking short distances or performing basic household
tasks. She states she often needs to rest during the day and has reduced participation in normal activities.
The fatigue is described as constant, not relieved by rest, and has gradually worsened. She denies acute illness, fever,
chest pain, shortness of breath at rest, dizziness, syncope, or recent infections. She reports decreased appetite, occasional
forgetfulness, and generalized weakness.
She denies melena, hematochezia, hematuria, or unintentional weight loss. Sleep is reported as fair, averaging 6 hours per
night, with occasional nighttime awakenings. No recent medication changes.
Associated Symptoms:
• Generalized weakness
• Decreased energy
• Reduced appetite
• Mild shortness of breath with exertion
• Occasional lightheadedness when standing
Past Medical History (PMH):
• Hypertension
• Type 2 Diabetes Mellitus
• Chronic Kidney Disease (Stage 3)
• Osteoarthritis
Past Surgical History (PSH):
• Cataract surgery (bilateral)
Medications:
• Lisinopril 10 mg PO daily
• Metformin 500 mg PO BID
• Acetaminophen PRN for joint pain
• Multivitamin daily
Allergies:
• No known drug allergies (NKDA)
Family History:
• Father: Deceased, myocardial infarction
• Mother: Deceased, type 2 diabetes
Female With Fatigue, Comprehensive SOAP Note,
Assessment, and Care Plan
I-Human case study of Chana Kumar, an 86-year-old female presenting with fatigue. Includes a detailed SOAP
note, geriatric assessment, differential diagnoses, and evidence-based nursing and medical care plan for healthcare
students.
• I-Human case study Chana Kumar
• Chana Kumar I-Human
• I-Human fatigue case study
Patient Information
• Name: Chana Kumar
• Age: 86 years
• Sex: Female
• Date: [Simulation Date]
• Setting: Primary Care / Geriatric Clinic
• Source of History: Patient and daughter (reliable)
S – Subjective
Chief Complaint (CC):
“I feel tired all the time.”
,History of Present Illness (HPI):
Chana Kumar is an 86-year-old female who presents with progressive fatigue over the past 3–4 months. The patient
reports feeling exhausted even after minimal activity, such as walking short distances or performing basic household
tasks. She states she often needs to rest during the day and has reduced participation in normal activities.
The fatigue is described as constant, not relieved by rest, and has gradually worsened. She denies acute illness, fever,
chest pain, shortness of breath at rest, dizziness, syncope, or recent infections. She reports decreased appetite, occasional
forgetfulness, and generalized weakness.
She denies melena, hematochezia, hematuria, or unintentional weight loss. Sleep is reported as fair, averaging 6 hours per
night, with occasional nighttime awakenings. No recent medication changes.
Associated Symptoms:
• Generalized weakness
• Decreased energy
• Reduced appetite
• Mild shortness of breath with exertion
• Occasional lightheadedness when standing
Past Medical History (PMH):
• Hypertension
• Type 2 Diabetes Mellitus
• Chronic Kidney Disease (Stage 3)
• Osteoarthritis
Past Surgical History (PSH):
• Cataract surgery (bilateral)
Medications:
• Lisinopril 10 mg PO daily
• Metformin 500 mg PO BID
• Acetaminophen PRN for joint pain
• Multivitamin daily
Allergies:
• No known drug allergies (NKDA)
Family History:
• Father: Deceased, myocardial infarction
• Mother: Deceased, type 2 diabetes
