Year-Old Male With Cough And Fatigue | Complete
Assessment, Diagnosis & SOAP Note NEWEST(2025
Update) WELL-ELABORATED
NURS 6512 Week 7 I-Human Case Study – 28- Year-Old Male With Cough And Fatigue | Complete Assessment, Diagnosis & SOAP Note NEWEST(2025 Update) WELL-ELABORATED i-Human Case Week #7: 28-Year-Old Male – Cough and Fatigue (2025 Update) Patient Information Age/Sex: 28-year-old male Height: 170 cm Weight: 68.2 kg BMI: 23.6 kg/m² (normal) Date of Visit: Week 7 encounter Setting: Outpatient primary care clinic ±n.Reason for Encounter “I’ve been coughing and feeling really tired for about two weeks.” Cç' Subjective Data Chief Complaint Cough and fatigue for 2 weeks. History of Present Illness (HPI) The patient reports a persistent, nonproductive cough for the past 14 days, initially mild but worsening over the last week. He notes fatigue, mild shortness of breath on exertion, and occasional chest tightness, but denies fever, chills, wheezing, hemoptysis, or chest pain. He took over-the-counter cough syrup with minimal relief. No recent travel, sick contacts, or exposure to tuberculosis. He works as an office administrator. Onset: 2 weeks ago Duration: Continuous Character: Dry cough Associated symptoms: Fatigue, mild SOB Aggravating: Cold air, talking
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