i-Human Case Week #7: REASON; Evaluation of
Cough and Fatigue 28-Year-Old Male CLASS 6512
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, Case Summary: 28-Year-Old with Fatigue and Cough
Reason for Encounter
• Chief Complaint: “I’ve been feeling tired and coughing for
the past couple of weeks.”
History of Present Illness (HPI)
The patient is a 28-year-old presenting with a 2-week history of
fatigue and a persistent cough.
• Cough: nonproductive → occasionally productive with small
amounts of clear/yellow sputum.
• Fatigue: gradual onset, worsening.
• Associated symptoms: mild shortness of breath with
exertion, low-grade fever, and night sweats.
• Denies chest pain, hemoptysis, or wheezing.
• No recent travel, but has been exposed to coworkers with
respiratory infections.
• No history of asthma, TB, or recent weight loss.
• Denies smoking; occasional alcohol use.
• No medication use.
Review of Systems (ROS)
• Constitutional: Positive for fatigue, mild fever, and night
sweats.
• HEENT: Denies sore throat, nasal congestion.
• Respiratory: Positive for cough, mild SOB, denies wheezing
or hemoptysis.
• Cardiovascular: Denies chest pain, palpitations.
• GI: Denies nausea, vomiting, diarrhea.
• GU: No dysuria or frequency.
Cough and Fatigue 28-Year-Old Male CLASS 6512
latest 2025.with soapnote
,
, Case Summary: 28-Year-Old with Fatigue and Cough
Reason for Encounter
• Chief Complaint: “I’ve been feeling tired and coughing for
the past couple of weeks.”
History of Present Illness (HPI)
The patient is a 28-year-old presenting with a 2-week history of
fatigue and a persistent cough.
• Cough: nonproductive → occasionally productive with small
amounts of clear/yellow sputum.
• Fatigue: gradual onset, worsening.
• Associated symptoms: mild shortness of breath with
exertion, low-grade fever, and night sweats.
• Denies chest pain, hemoptysis, or wheezing.
• No recent travel, but has been exposed to coworkers with
respiratory infections.
• No history of asthma, TB, or recent weight loss.
• Denies smoking; occasional alcohol use.
• No medication use.
Review of Systems (ROS)
• Constitutional: Positive for fatigue, mild fever, and night
sweats.
• HEENT: Denies sore throat, nasal congestion.
• Respiratory: Positive for cough, mild SOB, denies wheezing
or hemoptysis.
• Cardiovascular: Denies chest pain, palpitations.
• GI: Denies nausea, vomiting, diarrhea.
• GU: No dysuria or frequency.
