IHUMAN CASE STUDY. CASSIDY
HARRINGTON 27-YEAR-OLD.
REASON FOR ENCOUNTER:
FATIGUE AND LISTLESSNESS.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
, 1. Patient Demographics & Identifying Data
• Name: Cassidy Harrington
• Age: 27 years old
• Gender: Female
• Date of Visit: __________________
• Reason for Encounter: Fatigue and listlessness.
• Source of History: Patient; appears able to provide a clear and reliable
history.
• General Appearance: 27-year-old woman who appears her stated age.
She is appropriately dressed and groomed but appears somewhat tired
and less energetic than usual.
• Level of Consciousness: Alert and awake, with appropriate responses
throughout the encounter.
• Communication: Speech is clear and coherent. She is able to describe
her symptoms and explain how the fatigue has been affecting her daily
routine.
• Mood/Behavior: Calm and cooperative, although she appears somewhat
subdued and lacks her usual energy.
• Reliability of History: History appears reliable based on the information
provided.
• Overall Impression: Cassidy presents for evaluation of persistent fatigue
and a noticeable lack of energy/listlessness, requiring assessment for
medical, nutritional, sleep-related, psychological, endocrine,
hematologic, and other possible causes.
2. Chief Complaint (CC)
Patient states:
• “I've been feeling really tired and I just don't have my usual energy.”
HARRINGTON 27-YEAR-OLD.
REASON FOR ENCOUNTER:
FATIGUE AND LISTLESSNESS.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
, 1. Patient Demographics & Identifying Data
• Name: Cassidy Harrington
• Age: 27 years old
• Gender: Female
• Date of Visit: __________________
• Reason for Encounter: Fatigue and listlessness.
• Source of History: Patient; appears able to provide a clear and reliable
history.
• General Appearance: 27-year-old woman who appears her stated age.
She is appropriately dressed and groomed but appears somewhat tired
and less energetic than usual.
• Level of Consciousness: Alert and awake, with appropriate responses
throughout the encounter.
• Communication: Speech is clear and coherent. She is able to describe
her symptoms and explain how the fatigue has been affecting her daily
routine.
• Mood/Behavior: Calm and cooperative, although she appears somewhat
subdued and lacks her usual energy.
• Reliability of History: History appears reliable based on the information
provided.
• Overall Impression: Cassidy presents for evaluation of persistent fatigue
and a noticeable lack of energy/listlessness, requiring assessment for
medical, nutritional, sleep-related, psychological, endocrine,
hematologic, and other possible causes.
2. Chief Complaint (CC)
Patient states:
• “I've been feeling really tired and I just don't have my usual energy.”
