“i-Human Case Study – Week 7:
Comprehensive Evaluation,
Diagnosis, and Outpatient
Management of a 28-Year-Old
Male Presenting with Persistent
Cough and Fatigue (Class
6512)”
,Full Patient Details
Patient Identification
• Name: Mark James Thompson
• Age: 28 years
• Gender: Male
• Date of Birth: July 12, 1997
• Race/Ethnicity: Caucasian
• Marital Status: Single
• Occupation: Software Engineer at a technology firm
• Education: Bachelor’s degree in Computer Science
• Class: 6512
• Visit Type: Outpatient – Week 7 i-Human Case
• Reason for Encounter: Evaluation of cough and
fatigue
History of Present Illness (HPI)
Mark Thompson is a 28-year-old male presenting with a
dry, persistent cough and generalized fatigue for the
past two weeks. He describes the cough as non-
productive, worse at night, and sometimes causes mild
shortness of breath during activity. He denies any fever,
chills, or chest pain, but notes occasional sore throat
and headache.
,He states he feels “worn out all the time” and has noticed
decreased appetite and concentration due to poor sleep
from nighttime coughing. He has tried acetaminophen
and herbal tea without significant relief.
There has been no recent travel, sick contacts, or
known exposure to tuberculosis or COVID-19.
Past Medical History (PMH)
• Generally healthy adult male
• No chronic medical conditions reported
• No history of asthma, allergies, or respiratory disease
Past Surgical History (PSH)
• Appendectomy at age 14, no complications
Family History
Relative Age/Status Medical History
Father 56, living Hypertension
Mother 54, living Healthy
Asthma (childhood,
Sibling (Sister) 26, living
resolved)
, Relative Age/Status Medical History
Maternal Myocardial infarction at
Deceased
Grandfather 68
Maternal
76, living Osteoarthritis
Grandmother
Paternal
80, living Type 2 Diabetes
Grandfather
Paternal
79, living Hypertension
Grandmother
Social History
• Living Situation: Lives alone in a one-bedroom
apartment
• Occupation: Full-time software engineer; works
remotely 8–10 hours/day
• Diet: Frequently eats take-out or prepackaged foods,
minimal fruits and vegetables
• Exercise: Sedentary lifestyle; occasional walking on
weekends
• Sleep: Poor quality due to coughing; averages 5
hours/night
• Tobacco Use: Never smoker
• Alcohol Use: Occasional (1–2 drinks/weekend)
• Illicit Drugs: Denies use
• Sexual History: Heterosexual, monogamous
relationship, uses condoms consistently
Comprehensive Evaluation,
Diagnosis, and Outpatient
Management of a 28-Year-Old
Male Presenting with Persistent
Cough and Fatigue (Class
6512)”
,Full Patient Details
Patient Identification
• Name: Mark James Thompson
• Age: 28 years
• Gender: Male
• Date of Birth: July 12, 1997
• Race/Ethnicity: Caucasian
• Marital Status: Single
• Occupation: Software Engineer at a technology firm
• Education: Bachelor’s degree in Computer Science
• Class: 6512
• Visit Type: Outpatient – Week 7 i-Human Case
• Reason for Encounter: Evaluation of cough and
fatigue
History of Present Illness (HPI)
Mark Thompson is a 28-year-old male presenting with a
dry, persistent cough and generalized fatigue for the
past two weeks. He describes the cough as non-
productive, worse at night, and sometimes causes mild
shortness of breath during activity. He denies any fever,
chills, or chest pain, but notes occasional sore throat
and headache.
,He states he feels “worn out all the time” and has noticed
decreased appetite and concentration due to poor sleep
from nighttime coughing. He has tried acetaminophen
and herbal tea without significant relief.
There has been no recent travel, sick contacts, or
known exposure to tuberculosis or COVID-19.
Past Medical History (PMH)
• Generally healthy adult male
• No chronic medical conditions reported
• No history of asthma, allergies, or respiratory disease
Past Surgical History (PSH)
• Appendectomy at age 14, no complications
Family History
Relative Age/Status Medical History
Father 56, living Hypertension
Mother 54, living Healthy
Asthma (childhood,
Sibling (Sister) 26, living
resolved)
, Relative Age/Status Medical History
Maternal Myocardial infarction at
Deceased
Grandfather 68
Maternal
76, living Osteoarthritis
Grandmother
Paternal
80, living Type 2 Diabetes
Grandfather
Paternal
79, living Hypertension
Grandmother
Social History
• Living Situation: Lives alone in a one-bedroom
apartment
• Occupation: Full-time software engineer; works
remotely 8–10 hours/day
• Diet: Frequently eats take-out or prepackaged foods,
minimal fruits and vegetables
• Exercise: Sedentary lifestyle; occasional walking on
weekends
• Sleep: Poor quality due to coughing; averages 5
hours/night
• Tobacco Use: Never smoker
• Alcohol Use: Occasional (1–2 drinks/weekend)
• Illicit Drugs: Denies use
• Sexual History: Heterosexual, monogamous
relationship, uses condoms consistently
