NURS 2026 | I-Human Week 9 | Shane Peterson Case Study | Annual Physical Exam – 49-Year-Old
Male
I-HUMAN WEEK 9 CASE STUDY NURS 2026 – ADVANCED HEALTH
ASSESSMENT SHANE PETERSON | 49-YEAR-OLD MALE | ANNUAL
PHYSICAL EXAM LATEST 2026/2027
I-HUMAN WEEK 9 CASE STUDY
NURS 2026 – Advanced Health Assessment
Shane Peterson | 49-Year-Old Male | Annual Physical Exam
SECTION 1: PATIENT DEMOGRAPHICS & ENCOUNTER OVERVIEW
Patient Name Shane Peterson
Age 49 years old
Sex Male
Race/Ethnicity Caucasian
Encounter Type Annual Physical Exam (Well Visit)
Setting Primary Care Clinic
Course NURS 2026 – Advanced Health Assessment
Week Week 9 – I-Human Virtual Patient Case
Insurance Private / Employer-sponsored
Marital Status Married
Occupation Mid-level manager (sedentary desk job)
SECTION 2: CHIEF COMPLAINT & HISTORY OF PRESENT ILLNESS
(HPI)
Page 1 | Confidential – Educational Use Only
, NURS 2026 | I-Human Week 9 | Shane Peterson Case Study | Annual Physical Exam – 49-Year-Old
Male
2.1 Chief Complaint (CC)
"Here for my yearly physical. I have been feeling more tired than usual and noticed some weight
gain over the past year."
2.2 History of Present Illness (HPI)
Shane Peterson is a 49-year-old Caucasian male presenting for his annual physical
examination. He reports an insidious onset of fatigue over the past 6–12 months, describing it
as persistent tiredness that does not improve with rest. He also notes approximately 15 lbs of
unintentional weight gain over the past year, which he attributes partly to reduced physical
activity and a stressful work environment.
He denies any chest pain, palpitations, syncope, or shortness of breath at rest. He does note
mild exertional dyspnea when climbing stairs, which he attributes to deconditioning. He reports
occasional mild headaches occurring 2–3 times per week, usually frontal, non-pulsatile, and
relieved by acetaminophen. He denies nausea, vomiting, hemoptysis, or hematuria.
He states his appetite has been slightly increased, with cravings for high-carbohydrate foods.
He reports waking up 1–2 times per night to urinate (nocturia), which he notes is new over the
past few months. He denies dysuria, frequency, or urgency beyond nocturia. He also notes
occasional blurry vision, mostly at the end of the day, but has not seen an optometrist recently.
2.3 HPI Mnemonic (OLDCARTS) – Fatigue
Onset Gradual, 6–12 months ago
Location Generalized fatigue; whole body
Duration Persistent, daily
Character Heaviness, low energy, difficulty concentrating
Aggravating Factors Physical activity, stress, poor sleep
Relieving Factors Rest provides minimal relief; caffeine use has increased
Timing Worst in the morning; afternoon slump present
Severity 5/10 impact on daily life
SECTION 3: PAST MEDICAL, SURGICAL, & FAMILY HISTORY
Page 2 | Confidential – Educational Use Only
Male
I-HUMAN WEEK 9 CASE STUDY NURS 2026 – ADVANCED HEALTH
ASSESSMENT SHANE PETERSON | 49-YEAR-OLD MALE | ANNUAL
PHYSICAL EXAM LATEST 2026/2027
I-HUMAN WEEK 9 CASE STUDY
NURS 2026 – Advanced Health Assessment
Shane Peterson | 49-Year-Old Male | Annual Physical Exam
SECTION 1: PATIENT DEMOGRAPHICS & ENCOUNTER OVERVIEW
Patient Name Shane Peterson
Age 49 years old
Sex Male
Race/Ethnicity Caucasian
Encounter Type Annual Physical Exam (Well Visit)
Setting Primary Care Clinic
Course NURS 2026 – Advanced Health Assessment
Week Week 9 – I-Human Virtual Patient Case
Insurance Private / Employer-sponsored
Marital Status Married
Occupation Mid-level manager (sedentary desk job)
SECTION 2: CHIEF COMPLAINT & HISTORY OF PRESENT ILLNESS
(HPI)
Page 1 | Confidential – Educational Use Only
, NURS 2026 | I-Human Week 9 | Shane Peterson Case Study | Annual Physical Exam – 49-Year-Old
Male
2.1 Chief Complaint (CC)
"Here for my yearly physical. I have been feeling more tired than usual and noticed some weight
gain over the past year."
2.2 History of Present Illness (HPI)
Shane Peterson is a 49-year-old Caucasian male presenting for his annual physical
examination. He reports an insidious onset of fatigue over the past 6–12 months, describing it
as persistent tiredness that does not improve with rest. He also notes approximately 15 lbs of
unintentional weight gain over the past year, which he attributes partly to reduced physical
activity and a stressful work environment.
He denies any chest pain, palpitations, syncope, or shortness of breath at rest. He does note
mild exertional dyspnea when climbing stairs, which he attributes to deconditioning. He reports
occasional mild headaches occurring 2–3 times per week, usually frontal, non-pulsatile, and
relieved by acetaminophen. He denies nausea, vomiting, hemoptysis, or hematuria.
He states his appetite has been slightly increased, with cravings for high-carbohydrate foods.
He reports waking up 1–2 times per night to urinate (nocturia), which he notes is new over the
past few months. He denies dysuria, frequency, or urgency beyond nocturia. He also notes
occasional blurry vision, mostly at the end of the day, but has not seen an optometrist recently.
2.3 HPI Mnemonic (OLDCARTS) – Fatigue
Onset Gradual, 6–12 months ago
Location Generalized fatigue; whole body
Duration Persistent, daily
Character Heaviness, low energy, difficulty concentrating
Aggravating Factors Physical activity, stress, poor sleep
Relieving Factors Rest provides minimal relief; caffeine use has increased
Timing Worst in the morning; afternoon slump present
Severity 5/10 impact on daily life
SECTION 3: PAST MEDICAL, SURGICAL, & FAMILY HISTORY
Page 2 | Confidential – Educational Use Only
