Comprehensive iHuman Case Study Week 7 (2026): 65-Year-Old Patient With Nausea and Fatigue | Full SOAP Note & Evidence-Based Management

Comprehensive iHuman Case Study – Week 7:
65-Year-Old Patient Presenting With Nausea
and Fatigue | Full SOAP Note and Evidence-
Based Management




Comprehensive iHuman Case Study – Week 7

65-Year-Old Patient With Nausea and Fatigue

Well-Detailed SOAP Case Study Report

S – Subjective

Chief Complaint (CC):

, “I’ve been feeling nauseous and extremely tired for about a week.”



History of Present Illness (HPI):



The patient is a 65-year-old adult presenting with progressive nausea and fatigue for the past 7 days.
Symptoms developed gradually and have persisted daily. Nausea is described as constant, worse in the
mornings, and not relieved by food. The patient denies vomiting but reports decreased appetite. Fatigue
is generalized and limits normal activities such as walking and household tasks.



The patient denies fever, chills, abdominal pain, chest pain, dyspnea, diarrhea, constipation,
hematemesis, melena, or recent illness exposure. No recent medication changes. No recent travel or
sick contacts.



Pain Assessment:



Denies pain (0/10).



Associated Symptoms:



Decreased appetite



Mild dizziness



Occasional lightheadedness



Past Medical History (PMH):



Hypertension



Type 2 Diabetes Mellitus