Week 7 i-Human Case Study | Complete Clinical Evaluation & SOAP Note for Older Adults with Nausea & Fatigue

Week #7 I Human Case Study: Complete Clinical
Evalua on and SOAP Note for Older Adults with
Nausea and Fa gue




Age: 65 years

Gender: Male

Chief Complaints: Nausea and fa gue

Se ng: Outpa ent primary care clinic

, Chief Complaint (CC)



“I’ve been feeling very red and nauseous for the past few days.”



History of Present Illness (HPI)



A 65-year-old male who presents with progressive fa gue and persistent nausea for the past 5
days. The nausea is intermi ent, non-projec le, and not associated with vomi ng. He reports a
reduced appe te and mild abdominal discomfort but denies abdominal pain, diarrhea, or
cons pa on.



The fa gue is generalized, worsens with minimal ac vity, and is not relieved by rest. He denies
fever, chills, chest pain, shortness of breath, dizziness, syncope, or recent illness. No recent
travel or dietary changes. He reports poor oral intake due to nausea.



Symptoms began gradually and have worsened over me.



Past Medical History (PMH)



Type 2 Diabetes Mellitus – 12 years



Hypertension – 15 years



Hyperlipidemia



Chronic Kidney Disease (Stage 2)