I-HUMAN CASE WEEK 7: EVALUATION OF COUGH AND FATIGUE – 28-YEAR-OLD MALE SOAP NOTE (COMMUNITY-ACQUIRED PNEUMONIA)

I-HUMAN CASE WEEK 7: EVALUATION OF COUGH
AND FATIGUE – 28-YEAR-OLD MALE SOAP NOTE
(COMMUNITY-ACQUIRED PNEUMONIA)

,Patient Summary:

 Age/Sex: 28-year-old male
 Height/Weight: 5’7’’ (170 cm), 150 lb (68.2 kg)
 Chief Complaint: Cough and fatigue
 Location: Outpatient clinic — equipped with X-ray, ECG, and
laboratory testing



Case Instructions (H&P+Dx Case Play Setup and Instructions):

 Mode:
o The assignment is in Learning Mode.
o Feedback is provided after each section submission.
o A final performance overview is generated after completing
the case.
 Attempts Available:
o You are permitted one attempt for this assignment.


� History of Present Illness (HPI)

Chief Complaint:

―I’ve been feeling tired and have had a cough for about two weeks.‖

HPI Details:

 Onset: About 2 weeks ago
 Course: Started as a mild dry cough; now more productive with
yellowish sputum.
 Duration: Persistent; occurs throughout the day, worse at night.
 Associated Symptoms:
o Fatigue, mild shortness of breath on exertion
o Low-grade fever (100.4°F / 38°C)
o Occasional chest tightness
 Aggravating Factors: Physical activity, lying down

,  Relieving Factors: Rest and fluids help slightly
 Severity: Moderate; interfering with work and sleep
 Previous Episodes: None reported
 Sick Contacts: Roommate recently had a ―chest cold‖
 COVID/Flu exposure: Denies recent exposure or travel



� Past Medical History

 No chronic medical conditions reported
 No history of asthma, allergies, or heart disease
 No hospitalizations or surgeries



� Medications

 Occasional over-the-counter acetaminophen for fever
 No prescription medications



� Allergies

 NKDA (No Known Drug Allergies)



��� Family History

 Father: Hypertension
 Mother: Healthy
 No family history of respiratory illness or cardiac disease



� Social History