i-Human Case Week 7: 28-Year-Old Male
Reason for Encounter: Fatigue and Cough
Location: Outpatient clinic with X-ray, ECG, and laboratory
capabilities
Full Case Summary & SOAP Note
,
, i-Human Case Week 7: 28-Year-Old Male
with Fatigue and Cough – Full Case
Summary & SOAP Note
Course Alignment: NURS 6512 – Advanced Health Assessment
Focus Area: Clinical Reasoning, Differential Diagnosis, and Evidence-Based History
Taking
Patient Demographics: 28-year-old male, Caucasian, presenting to an outpatient
primary care clinic in a suburban setting.
Chief Complaint: "I’ve had this nagging cough and I’m just exhausted all the time for the
past three weeks."
1. History of Presenting Illness (HPI) – Detailed Chronology
Onset and Duration: The patient reports symptoms began approximately 21 days ago.
Initially, he thought he was developing a common cold after attending a large indoor social
gathering. He noted a mild scratchy throat and occasional sneezing for the first 2–3 days.
Evolution of Symptoms: Over the next week, the sore throat resolved, but a dry, non-
productive cough emerged. By day 10, the cough became more frequent and bothersome,
occurring in paroxysms lasting 5–10 minutes, particularly at night and after lying down. Around
day 14, the patient began experiencing significant fatigue—he describes it as a "bone-tired"
feeling not relieved by sleep. He used to run 3 miles four times per week but now struggles to
climb one flight of stairs without feeling winded and needing to rest.
Cough Characteristics:
• Quality: Dry (non-productive) for the first 2 weeks; now occasionally produces scant,
clear-to-white sputum (no blood, no green/yellow purulence)
Reason for Encounter: Fatigue and Cough
Location: Outpatient clinic with X-ray, ECG, and laboratory
capabilities
Full Case Summary & SOAP Note
,
, i-Human Case Week 7: 28-Year-Old Male
with Fatigue and Cough – Full Case
Summary & SOAP Note
Course Alignment: NURS 6512 – Advanced Health Assessment
Focus Area: Clinical Reasoning, Differential Diagnosis, and Evidence-Based History
Taking
Patient Demographics: 28-year-old male, Caucasian, presenting to an outpatient
primary care clinic in a suburban setting.
Chief Complaint: "I’ve had this nagging cough and I’m just exhausted all the time for the
past three weeks."
1. History of Presenting Illness (HPI) – Detailed Chronology
Onset and Duration: The patient reports symptoms began approximately 21 days ago.
Initially, he thought he was developing a common cold after attending a large indoor social
gathering. He noted a mild scratchy throat and occasional sneezing for the first 2–3 days.
Evolution of Symptoms: Over the next week, the sore throat resolved, but a dry, non-
productive cough emerged. By day 10, the cough became more frequent and bothersome,
occurring in paroxysms lasting 5–10 minutes, particularly at night and after lying down. Around
day 14, the patient began experiencing significant fatigue—he describes it as a "bone-tired"
feeling not relieved by sleep. He used to run 3 miles four times per week but now struggles to
climb one flight of stairs without feeling winded and needing to rest.
Cough Characteristics:
• Quality: Dry (non-productive) for the first 2 weeks; now occasionally produces scant,
clear-to-white sputum (no blood, no green/yellow purulence)
