i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
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, i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
iHuman Case Study: Cough and Fatigue
Patient Information
Name: Smith
Age: 28years
Gender: Male
Occupation: School teacher
Date of Visit: October 11, 2025
Chief Complaint
“I’ve been coughing for about two weeks and feeling really tired lately.”
History of Present Illness (HPI)
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, i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
Smith reports a persistent cough for the past 14 days, initially dry but now producing small
amounts of yellowish sputum. He denies chest pain but notes mild shortness of breath when
climbing stairs.
He reports fatigue, loss of appetite, and unintentional weight loss of about 3 kg in the past
month. No recent travel, but he works in a crowded classroom environment. He denies smoking
but admits to occasional alcohol use.
Past Medical History
Mild hypertension, managed with amlodipine.
No history of asthma, diabetes, or tuberculosis.
Family History
Father had pulmonary tuberculosis at age 60.
Mother has hypertension.
Social History
Lives with wife and two children.
No smoking history.
Drinks socially on weekends.
Works full-time as a teacher.
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, i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
Review of Systems
General: Fatigue, weight loss, low-grade fever (evenings).
Respiratory: Cough, sputum production, mild shortness of breath.
Cardiovascular: No palpitations or chest pain.
GI: No nausea or vomiting.
Neuro: No dizziness or headache.
Physical Examination
System Findings
General Appears tired, mild pallor noted. No cyanosis.
Vitals Temp: 37.8°C, HR: 92 bpm, BP: 128/84 mmHg, RR: 20/min, O₂ sat: 95%
Respiratory Crackles heard in upper right lung, no wheezing
Cardiac Regular rhythm, no murmurs
Abdomen Soft, non-tender
Skin No rash, mild pallor present
Diagnostic Tests Ordered
1. Chest X-ray – shows patchy opacities in the upper right lung.
2. Sputum smear for AFB (Acid-Fast Bacilli) – positive.
3. Complete Blood Count (CBC) – mild anemia (Hb 11.2 g/dL).
4. ESR (Erythrocyte Sedimentation Rate) – elevated.
5. HIV test – negative.
Assessment
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Presenting with Cough and Fatigue
(Week #7, Class 6512)
1|Page
, i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
iHuman Case Study: Cough and Fatigue
Patient Information
Name: Smith
Age: 28years
Gender: Male
Occupation: School teacher
Date of Visit: October 11, 2025
Chief Complaint
“I’ve been coughing for about two weeks and feeling really tired lately.”
History of Present Illness (HPI)
2|Page
, i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
Smith reports a persistent cough for the past 14 days, initially dry but now producing small
amounts of yellowish sputum. He denies chest pain but notes mild shortness of breath when
climbing stairs.
He reports fatigue, loss of appetite, and unintentional weight loss of about 3 kg in the past
month. No recent travel, but he works in a crowded classroom environment. He denies smoking
but admits to occasional alcohol use.
Past Medical History
Mild hypertension, managed with amlodipine.
No history of asthma, diabetes, or tuberculosis.
Family History
Father had pulmonary tuberculosis at age 60.
Mother has hypertension.
Social History
Lives with wife and two children.
No smoking history.
Drinks socially on weekends.
Works full-time as a teacher.
3|Page
, i-Human Case Study: 28-Year-Old Male
Presenting with Cough and Fatigue
(Week #7, Class 6512)
Review of Systems
General: Fatigue, weight loss, low-grade fever (evenings).
Respiratory: Cough, sputum production, mild shortness of breath.
Cardiovascular: No palpitations or chest pain.
GI: No nausea or vomiting.
Neuro: No dizziness or headache.
Physical Examination
System Findings
General Appears tired, mild pallor noted. No cyanosis.
Vitals Temp: 37.8°C, HR: 92 bpm, BP: 128/84 mmHg, RR: 20/min, O₂ sat: 95%
Respiratory Crackles heard in upper right lung, no wheezing
Cardiac Regular rhythm, no murmurs
Abdomen Soft, non-tender
Skin No rash, mild pallor present
Diagnostic Tests Ordered
1. Chest X-ray – shows patchy opacities in the upper right lung.
2. Sputum smear for AFB (Acid-Fast Bacilli) – positive.
3. Complete Blood Count (CBC) – mild anemia (Hb 11.2 g/dL).
4. ESR (Erythrocyte Sedimentation Rate) – elevated.
5. HIV test – negative.
Assessment
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