1|Page
I HUMAN CASE STUDY — WEEK #7 FOR A 65-
YEAR-OLD MALE — REASON FOR ENCOUNTER:
NAUSEA & FATIGUE - LOCATION: OUTPATIENT
PRIMARY CARE CLINIC WITH LAB AND BASIC
IMAGING LATEST WITH SOAP NOTE
,2|Page
1. General Case Informationg; g;
Case title & summary:
g; g; g;
Older adult with 2–3 weeks of progressive fatigue and intermittent nausea. The
g; g; g; g; g; g; g; g; g; g; g;
g; case explores cardiopulmonary, metabolic, hematologic, gastrointestinal, renal,
g; g; g; g; g; g;
g; endocrine, infectious, medication-related and oncologic causes of nonspecific
g; g; g; g; g; g; g;
g; constitutional symptoms in an older adult, and outlines a safe outpatient
g; g; g; g; g; g; g; g; g; g;
diagnostic and management approach.
g; g; g; g;
Reason for encounter:
g; g;
Progressive fatigue and episodic nausea.
g; g; g; g;
Patient demographics:
g;
• Age: 65 years
g; g;
• Sex: Male g;
• Height: 178 cm (5′10″) g; g; g;
• Weight: 88 kg (194 lb) — BMI ≈ 27.8 kg/m²
g; g; g; g; g; g; g; g; g;
Case mode: Learning / exam simulation
g; g; g; g; g;
Case location: Outpatient clinic with phlebotomy, ECG, and X-ray access
g; g; g; g; g; g; g; g; g;
Attempts allowed: Unlimited (learning mode)
g; g; g; g;
, 3|Page
2. Chief Complaint (CC) g; g;
“I’ve felt incredibly tired for a few weeks and I keep feeling nauseated —
g; g; g; g; g; g; g; g; g; g; g; g; g;
sometimes I can’t eat.”
g; g; g; g;
3. History of Present Illness (HPI) g; g; g; g;
The patient reports 3 weeks of progressive fatigue and intermittent nausea.
g; g; g; g; g; g; g; g; g; g;
Nausea occurs several times per day, sometimes worse in the morning and
g; g; g; g; g; g; g; g; g; g; g; g;
after meals, rarely associated with emesis (1 episode in the past week). He
g; g; g; g; g; g; g; g; g; g; g; g; g;
g; reports reduced appetite and modest unintentional weight loss of
g; g; g; g; g; g; g; g;
approximately 3 kg (about 7 lb) over 3 weeks. He denies overt hematemesis,
g; g; g; g; g; g; g; g; g; g; g; g; g;
melena, or visible blood in stool, but admits stools have been darker
g; g; g; g; g; g; g; g; g; g; g; g;
occasionally and he attributes that to iron supplements he took briefly last
g; g; g; g; g; g; g; g; g; g; g; g;
g; month.
Fatigue limits his usual activities — walks slower, naps more. He describes
g; g; g; g; g; g; g; g; g; g; g;
g; mild exertional dyspnea when climbing one flight of stairs (new). No chest
g; g; g; g; g; g; g; g; g; g; g;
pain, palpitations, syncope, focal weakness, or new focal neurologic
g; g; g; g; g; g; g; g; g;
symptoms. No fevers or night sweats reported. No recent travel. No known
g; g; g; g; g; g; g; g; g; g; g; g;
sick contacts.
g; g;
Diet: appetite decreased; reports more coffee than usual. Drinks alcohol
g; g; g; g; g; g; g; g; g;
occasionally (1–2 drinks/week). Has been taking over-the-counter naproxen for
g; g; g; g; g; g; g; g; g;
g; mild knee pain intermittently for several months. Takes several prescribed meds
g; g; g; g; g; g; g; g; g; g;
g; (see PMH/meds section).
g; g;
4. Past Medical History (PMH)
g; g; g;
I HUMAN CASE STUDY — WEEK #7 FOR A 65-
YEAR-OLD MALE — REASON FOR ENCOUNTER:
NAUSEA & FATIGUE - LOCATION: OUTPATIENT
PRIMARY CARE CLINIC WITH LAB AND BASIC
IMAGING LATEST WITH SOAP NOTE
,2|Page
1. General Case Informationg; g;
Case title & summary:
g; g; g;
Older adult with 2–3 weeks of progressive fatigue and intermittent nausea. The
g; g; g; g; g; g; g; g; g; g; g;
g; case explores cardiopulmonary, metabolic, hematologic, gastrointestinal, renal,
g; g; g; g; g; g;
g; endocrine, infectious, medication-related and oncologic causes of nonspecific
g; g; g; g; g; g; g;
g; constitutional symptoms in an older adult, and outlines a safe outpatient
g; g; g; g; g; g; g; g; g; g;
diagnostic and management approach.
g; g; g; g;
Reason for encounter:
g; g;
Progressive fatigue and episodic nausea.
g; g; g; g;
Patient demographics:
g;
• Age: 65 years
g; g;
• Sex: Male g;
• Height: 178 cm (5′10″) g; g; g;
• Weight: 88 kg (194 lb) — BMI ≈ 27.8 kg/m²
g; g; g; g; g; g; g; g; g;
Case mode: Learning / exam simulation
g; g; g; g; g;
Case location: Outpatient clinic with phlebotomy, ECG, and X-ray access
g; g; g; g; g; g; g; g; g;
Attempts allowed: Unlimited (learning mode)
g; g; g; g;
, 3|Page
2. Chief Complaint (CC) g; g;
“I’ve felt incredibly tired for a few weeks and I keep feeling nauseated —
g; g; g; g; g; g; g; g; g; g; g; g; g;
sometimes I can’t eat.”
g; g; g; g;
3. History of Present Illness (HPI) g; g; g; g;
The patient reports 3 weeks of progressive fatigue and intermittent nausea.
g; g; g; g; g; g; g; g; g; g;
Nausea occurs several times per day, sometimes worse in the morning and
g; g; g; g; g; g; g; g; g; g; g; g;
after meals, rarely associated with emesis (1 episode in the past week). He
g; g; g; g; g; g; g; g; g; g; g; g; g;
g; reports reduced appetite and modest unintentional weight loss of
g; g; g; g; g; g; g; g;
approximately 3 kg (about 7 lb) over 3 weeks. He denies overt hematemesis,
g; g; g; g; g; g; g; g; g; g; g; g; g;
melena, or visible blood in stool, but admits stools have been darker
g; g; g; g; g; g; g; g; g; g; g; g;
occasionally and he attributes that to iron supplements he took briefly last
g; g; g; g; g; g; g; g; g; g; g; g;
g; month.
Fatigue limits his usual activities — walks slower, naps more. He describes
g; g; g; g; g; g; g; g; g; g; g;
g; mild exertional dyspnea when climbing one flight of stairs (new). No chest
g; g; g; g; g; g; g; g; g; g; g;
pain, palpitations, syncope, focal weakness, or new focal neurologic
g; g; g; g; g; g; g; g; g;
symptoms. No fevers or night sweats reported. No recent travel. No known
g; g; g; g; g; g; g; g; g; g; g; g;
sick contacts.
g; g;
Diet: appetite decreased; reports more coffee than usual. Drinks alcohol
g; g; g; g; g; g; g; g; g;
occasionally (1–2 drinks/week). Has been taking over-the-counter naproxen for
g; g; g; g; g; g; g; g; g;
g; mild knee pain intermittently for several months. Takes several prescribed meds
g; g; g; g; g; g; g; g; g; g;
g; (see PMH/meds section).
g; g;
4. Past Medical History (PMH)
g; g; g;
