Study – 28-Year-Old Male with Cough
and Fatigue (2025 Update)
Case Overview
Patient Name: Mr. Brian Collins
Age: 28 years
Sex: Male
Date of Encounter: April 15, 2025
Setting: Primary Care Clinic
Chief Complaint
"I’ve had this cough and I just can’t shake off the tiredness for the past two weeks."
History of Present Illness (HPI)
Brian Collins is a 28-year-old male presenting with a persistent dry cough and fatigue
lasting for two weeks.
The cough began gradually, is worse at night, and occasionally accompanied by mild chest
tightness. He denies hemoptysis or significant shortness of breath.
Fatigue is constant and impacts daily work performance. He denies fever, chills, night
sweats, or weight loss.
He has mild nasal congestion but no sore throat. Denies recent travel or tuberculosis
exposure.
Past Medical History
Mild seasonal allergies; no asthma, diabetes, hypertension, or cardiac disease.
Social History
Non-smoker, social alcohol use, accountant, sedentary lifestyle, irregular exercise, lives with
wife and daughter, no recent travel.
Family History
Father: hypertension; Mother: hypothyroidism; no asthma, TB, or malignancy.