,SHANE PETERSON I HUMAN CASE PRESENTS
ANNUAL PHYSICAL CASE STUDY 2025
Chamberlain nursing college
Institution: Chamberlain University Nursing College
i-Human Case (2025)
Patient Name: Shane Peterson
Age: 50 years
Gender: Male
Encounter Type: Annual Physical Exam
Setting: Outpatient Primary Care Clinic
S: Subjective
• Chief Complaint (CC):
"Just here for my yearly checkup."
• History of Present Illness (HPI):
Shane is a 50-year-old male presenting for an annual
physical exam. He has no acute complaints but is
interested in staying on top of his health. He reports
feeling generally well with no current pain, fever,
cough, weight changes, or fatigue. He denies any
, cardiovascular, respiratory, gastrointestinal, or
genitourinary symptoms.
• Past Medical History (PMH):
o Hypertension (diagnosed at 45)
o Hyperlipidemia
o No surgeries
o No hospitalizations
• Medications:
o Lisinopril 10 mg daily
o Atorvastatin 20 mg nightly
• Allergies:
o NKDA (No Known Drug Allergies)
• Family History:
o Father: MI at age 65
o Mother: Type 2 Diabetes
o Siblings: Healthy
• Social History:
o Non-smoker
o Rare alcohol use
o Diet: High in processed foods
o Sedentary lifestyle
o Works as an accountant
o Lives with spouse, has two children
• Immunizations:
o Up to date on influenza, Tdap, COVID-19
o No recent shingles or pneumococcal vaccine
• Screenings:
o Last colonoscopy at age 45 – normal
ANNUAL PHYSICAL CASE STUDY 2025
Chamberlain nursing college
Institution: Chamberlain University Nursing College
i-Human Case (2025)
Patient Name: Shane Peterson
Age: 50 years
Gender: Male
Encounter Type: Annual Physical Exam
Setting: Outpatient Primary Care Clinic
S: Subjective
• Chief Complaint (CC):
"Just here for my yearly checkup."
• History of Present Illness (HPI):
Shane is a 50-year-old male presenting for an annual
physical exam. He has no acute complaints but is
interested in staying on top of his health. He reports
feeling generally well with no current pain, fever,
cough, weight changes, or fatigue. He denies any
, cardiovascular, respiratory, gastrointestinal, or
genitourinary symptoms.
• Past Medical History (PMH):
o Hypertension (diagnosed at 45)
o Hyperlipidemia
o No surgeries
o No hospitalizations
• Medications:
o Lisinopril 10 mg daily
o Atorvastatin 20 mg nightly
• Allergies:
o NKDA (No Known Drug Allergies)
• Family History:
o Father: MI at age 65
o Mother: Type 2 Diabetes
o Siblings: Healthy
• Social History:
o Non-smoker
o Rare alcohol use
o Diet: High in processed foods
o Sedentary lifestyle
o Works as an accountant
o Lives with spouse, has two children
• Immunizations:
o Up to date on influenza, Tdap, COVID-19
o No recent shingles or pneumococcal vaccine
• Screenings:
o Last colonoscopy at age 45 – normal
