NRNP 6531 Week 6 iHuman Case
Study: Herbie Romero -
Respiratory Symptoms | Latest
2025/2026 A+ Guide
,Thank you for providing the **full patient introduction and HPI** for **Herbie Romero**, a 52-year-old
Hispanic male presenting with **cough and trouble breathing** for 10 days.
Below is a **complete, ready-to-submit SOAP note** including a full **physical exam** section,
differential diagnosis, and evidence-based management plan appropriate for an outpatient primary care
clinic.
---
# SOAP NOTE – Outpatient Primary Care Clinic
**Patient Name:** Herbie Romero
**DOB:** [MM/DD/YYYY] (Age: 52 years)
**Date of Visit:** [MM/DD/YYYY]
**Ethnicity:** Hispanic
**Source of History:** Self (reliable historian)
**Setting:** Outpatient primary care clinic
**Encounter Type:** New problem – acute
, ---
## SUBJECTIVE (S)
**Chief Complaint (patient’s words):**
“I’ve had this cough and trouble breathing.”
**History of Present Illness (OLD CARTS Format):**
| Element | Finding |
|---------|---------|
| **Onset** | Symptoms began approximately **10 days ago** and have gradually worsened over
time. |
| **Location** | Chest and lungs – diffuse tightness, no focal pleuritic localization. |
| **Duration** | Persistent cough throughout the day, worse at **night and early morning**. |
| **Character** | **Productive cough** with **thick yellow-green sputum**; chest tightness;
wheezing; shortness of breath with activity; fatigue. |
| **Aggravating factors** | Activity/exertion, lying flat at night (nocturnal symptoms), cold air (not
specified but common). |
| **Relieving factors** | Sitting upright, rest (partial relief). |
| **Timing** | Symptoms are constant during the day but worsen at night and early morning. |
| **Severity** | Moderate – patient is able to speak in full sentences but becomes short of breath with
minimal exertion (e.g., walking across a room). |
**Additional HPI Details:**
- Patient denies fever, chills, or night sweats.
- Denies hemoptysis (blood in sputum).
- Denies chest pain (sharp or pressure-like).
- Denies lower extremity edema or calf pain.
- No recent travel, no known sick contacts (though seasonally appropriate).
Study: Herbie Romero -
Respiratory Symptoms | Latest
2025/2026 A+ Guide
,Thank you for providing the **full patient introduction and HPI** for **Herbie Romero**, a 52-year-old
Hispanic male presenting with **cough and trouble breathing** for 10 days.
Below is a **complete, ready-to-submit SOAP note** including a full **physical exam** section,
differential diagnosis, and evidence-based management plan appropriate for an outpatient primary care
clinic.
---
# SOAP NOTE – Outpatient Primary Care Clinic
**Patient Name:** Herbie Romero
**DOB:** [MM/DD/YYYY] (Age: 52 years)
**Date of Visit:** [MM/DD/YYYY]
**Ethnicity:** Hispanic
**Source of History:** Self (reliable historian)
**Setting:** Outpatient primary care clinic
**Encounter Type:** New problem – acute
, ---
## SUBJECTIVE (S)
**Chief Complaint (patient’s words):**
“I’ve had this cough and trouble breathing.”
**History of Present Illness (OLD CARTS Format):**
| Element | Finding |
|---------|---------|
| **Onset** | Symptoms began approximately **10 days ago** and have gradually worsened over
time. |
| **Location** | Chest and lungs – diffuse tightness, no focal pleuritic localization. |
| **Duration** | Persistent cough throughout the day, worse at **night and early morning**. |
| **Character** | **Productive cough** with **thick yellow-green sputum**; chest tightness;
wheezing; shortness of breath with activity; fatigue. |
| **Aggravating factors** | Activity/exertion, lying flat at night (nocturnal symptoms), cold air (not
specified but common). |
| **Relieving factors** | Sitting upright, rest (partial relief). |
| **Timing** | Symptoms are constant during the day but worsen at night and early morning. |
| **Severity** | Moderate – patient is able to speak in full sentences but becomes short of breath with
minimal exertion (e.g., walking across a room). |
**Additional HPI Details:**
- Patient denies fever, chills, or night sweats.
- Denies hemoptysis (blood in sputum).
- Denies chest pain (sharp or pressure-like).
- Denies lower extremity edema or calf pain.
- No recent travel, no known sick contacts (though seasonally appropriate).
