Comprehensive I Human Case Study 65-Year-Old Pa ent
with Nausea and Fa gue - Week #7 Detailed Report and
Analysis
1. Pa ent Informa on
Age: 65 years
Gender: Male
Ethnicity: African American
Marital Status: Married
Occupa on: Re red accountant
Source of Informa on: Pa ent (reliable historian)
Chief Complaint: “I have been feeling nauseated and extremely red for the past week.”
, 2. History of Present Illness (HPI)
The pa ent is a 65-year-old male who presents with a 7-day history of persistent nausea and
generalized fa gue. The nausea is described as constant, non-bilious, and non-bloody, with no
episodes of vomi ng. He reports decreased appe te and early sa ety. Fa gue is progressive and
interferes with daily ac vi es such as walking short distances and comple ng household tasks.
Symptoms began gradually and have worsened over the past few days. The pa ent denies fever,
chills, chest pain, shortness of breath, diarrhea, cons pa on, hematemesis, or melena. He
reports mild dizziness when standing but denies syncope. There is no recent travel, sick
contacts, or consump on of undercooked food.
He reports poor oral intake due to nausea and admits to missing some meals. He has not tried
any over-the-counter medica ons for symptom relief.
3. Past Medical History (PMH)
Type 2 Diabetes Mellitus – diagnosed 12 years ago
Hypertension – diagnosed 15 years ago
Hyperlipidemia
Chronic Kidney Disease (Stage 3)
Past Surgical History
Appendectomy at age 25
4. Medica ons
Me ormin 1000 mg PO twice daily
Lisinopril 20 mg PO daily
Amlodipine 10 mg PO daily
Atorvasta n 40 mg PO nightly
Aspirin 81 mg PO daily
5. Allergies
with Nausea and Fa gue - Week #7 Detailed Report and
Analysis
1. Pa ent Informa on
Age: 65 years
Gender: Male
Ethnicity: African American
Marital Status: Married
Occupa on: Re red accountant
Source of Informa on: Pa ent (reliable historian)
Chief Complaint: “I have been feeling nauseated and extremely red for the past week.”
, 2. History of Present Illness (HPI)
The pa ent is a 65-year-old male who presents with a 7-day history of persistent nausea and
generalized fa gue. The nausea is described as constant, non-bilious, and non-bloody, with no
episodes of vomi ng. He reports decreased appe te and early sa ety. Fa gue is progressive and
interferes with daily ac vi es such as walking short distances and comple ng household tasks.
Symptoms began gradually and have worsened over the past few days. The pa ent denies fever,
chills, chest pain, shortness of breath, diarrhea, cons pa on, hematemesis, or melena. He
reports mild dizziness when standing but denies syncope. There is no recent travel, sick
contacts, or consump on of undercooked food.
He reports poor oral intake due to nausea and admits to missing some meals. He has not tried
any over-the-counter medica ons for symptom relief.
3. Past Medical History (PMH)
Type 2 Diabetes Mellitus – diagnosed 12 years ago
Hypertension – diagnosed 15 years ago
Hyperlipidemia
Chronic Kidney Disease (Stage 3)
Past Surgical History
Appendectomy at age 25
4. Medica ons
Me ormin 1000 mg PO twice daily
Lisinopril 20 mg PO daily
Amlodipine 10 mg PO daily
Atorvasta n 40 mg PO nightly
Aspirin 81 mg PO daily
5. Allergies
