Marvin Webster- I-Human
Patient and Encounter
Patient: Marvin Webster
Age: 18-year-old male college student
Reason for encounter: Fatigue and cough
Setting: Outpatient clinic with laboratory, ECG, and X-ray capabilities
PMH: Childhood asthma
Current complaint: Approximately 4 days of fatigue, sore throat, headache, dry cough, myalgias/body
aches, and chills
Exposure: Sick roommate/contact
Preventive care: Has not received current influenza vaccine and is behind on COVID
vaccination/booster.
History
General
● How can I help you today?
● What symptom is bothering you the most?
● How does this affect your daily activities/school?
● When did your symptoms begin?
● Have the symptoms been getting better or worse?
● Has anyone else you know developed similar symptoms?
Fatigue
● When did the fatigue start?
● Is the fatigue constant or intermittent?
● Is it related to physical activity?
● Does rest improve it?
● How severe is the fatigue?
● Has it prevented you from attending school or normal activities?
Cough
● When did the cough begin?
● Is it dry or productive?
● Are you coughing up sputum?
● What color is the sputum?
● Is the cough worse at a particular time of day?
● Any shortness of breath?
● Any wheezing?
● Any chest pain?
● Any hemoptysis?
Infectious symptoms
● Have you had a fever?
● Chills?
Patient and Encounter
Patient: Marvin Webster
Age: 18-year-old male college student
Reason for encounter: Fatigue and cough
Setting: Outpatient clinic with laboratory, ECG, and X-ray capabilities
PMH: Childhood asthma
Current complaint: Approximately 4 days of fatigue, sore throat, headache, dry cough, myalgias/body
aches, and chills
Exposure: Sick roommate/contact
Preventive care: Has not received current influenza vaccine and is behind on COVID
vaccination/booster.
History
General
● How can I help you today?
● What symptom is bothering you the most?
● How does this affect your daily activities/school?
● When did your symptoms begin?
● Have the symptoms been getting better or worse?
● Has anyone else you know developed similar symptoms?
Fatigue
● When did the fatigue start?
● Is the fatigue constant or intermittent?
● Is it related to physical activity?
● Does rest improve it?
● How severe is the fatigue?
● Has it prevented you from attending school or normal activities?
Cough
● When did the cough begin?
● Is it dry or productive?
● Are you coughing up sputum?
● What color is the sputum?
● Is the cough worse at a particular time of day?
● Any shortness of breath?
● Any wheezing?
● Any chest pain?
● Any hemoptysis?
Infectious symptoms
● Have you had a fever?
● Chills?
