i-HUMAN CASE STUDY WEEK 7: EVALUATION
OF A 28-YEAR-OLD MALE WITH PERSISTENT
COUGH AND FATIGUE
,
, 1. FULL CASE SUMMARY
Patient: Roman Hernandez (pseudonym), 28-year-old Hispanic male,
construction worker
Setting: Outpatient primary care clinic with on-site laboratory, chest X-
ray, and spirometry
Chief Complaint: "I've had this nagging dry cough and feel wiped out
all the time for about two weeks now."
HPI: Gradual onset of nonproductive, hacking cough 14 days ago,
following a mild URI (sore throat, nasal congestion) that resolved in 48
hours. Cough occurs 5–10 times/hour during the day and worsens in the
evenings/night, disrupting sleep. Associated mild exertional dyspnea
(3/10), generalized progressive fatigue ("bone-tired") interfering with
work, and decreased appetite without weight loss. Denies fever, chills,
night sweats, hemoptysis, chest pain, wheezing at rest, recent travel, or
sick contacts. Tried OTC guaifenesin 200 mg BID × 3 days without
relief.
PMH: No chronic medical conditions. Appendectomy at age 12.
Immunizations up-to-date (influenza, COVID-19 boosters September
2025).
Medications: Guaifenesin (discontinued), acetaminophen PRN. No
prescription medications. Allergies: NKDA.
Family History: Father—hypertension; Mother—hypothyroidism. No
family history of asthma, TB, or lung cancer.
Social History: Construction worker (dusty outdoor environment),
nonsmoker, occasional alcohol (1–2 drinks/week), denies drugs,
exercises 3×/week (jogs), balanced diet, lives alone, no pets.
Key Objective Findings (from i-Human case data):
• Vitals: Febrile? No fever reported. Exertional desaturation 96% →
93%.
OF A 28-YEAR-OLD MALE WITH PERSISTENT
COUGH AND FATIGUE
,
, 1. FULL CASE SUMMARY
Patient: Roman Hernandez (pseudonym), 28-year-old Hispanic male,
construction worker
Setting: Outpatient primary care clinic with on-site laboratory, chest X-
ray, and spirometry
Chief Complaint: "I've had this nagging dry cough and feel wiped out
all the time for about two weeks now."
HPI: Gradual onset of nonproductive, hacking cough 14 days ago,
following a mild URI (sore throat, nasal congestion) that resolved in 48
hours. Cough occurs 5–10 times/hour during the day and worsens in the
evenings/night, disrupting sleep. Associated mild exertional dyspnea
(3/10), generalized progressive fatigue ("bone-tired") interfering with
work, and decreased appetite without weight loss. Denies fever, chills,
night sweats, hemoptysis, chest pain, wheezing at rest, recent travel, or
sick contacts. Tried OTC guaifenesin 200 mg BID × 3 days without
relief.
PMH: No chronic medical conditions. Appendectomy at age 12.
Immunizations up-to-date (influenza, COVID-19 boosters September
2025).
Medications: Guaifenesin (discontinued), acetaminophen PRN. No
prescription medications. Allergies: NKDA.
Family History: Father—hypertension; Mother—hypothyroidism. No
family history of asthma, TB, or lung cancer.
Social History: Construction worker (dusty outdoor environment),
nonsmoker, occasional alcohol (1–2 drinks/week), denies drugs,
exercises 3×/week (jogs), balanced diet, lives alone, no pets.
Key Objective Findings (from i-Human case data):
• Vitals: Febrile? No fever reported. Exertional desaturation 96% →
93%.
