WITH COUGH AND FATIGUE EXPERT SOAP NOTE & CLINICAL
ASSESSMENT GUIDE FOR SEIDEL'S GUIDE TO PHYSICAL
EXAMINATION, 10TH EDITION BY JANE W. BALL, JOYCE E.
DAINS, JOHN A. FLYNN, BARRY S. SOLOMON LATEST EDITION
2026-2027 WITH ALL CORRECT ANSWERS QUALIFIED 100%
PASS!!!
,Comprehensive Practice Case Study
2026–2027 NURS 6512 Week 7: 28-Year-Old Male with Cough and Fatigue
SOAP Note & Clinical Assessment Practice Guide
This practice scenario focuses on advanced health assessment, respiratory examination,
differential diagnosis, patient education, and evidence-based clinical reasoning for a young adult
presenting with cough and fatigue.
Patient Information
Name: J.T.
Age: 28 years
Gender: Male
Chief Complaint:
I’ve had a cough and fatigue for about two weeks.
SUBJECTIVE DATA
History of Present Illness (HPI)
The patient is a 28-year-old male presenting with persistent cough and worsening fatigue for
approximately 14 days. He reports a dry cough that occasionally becomes productive with small
amounts of yellow sputum. The cough is worse at night and interrupts sleep. He also reports
generalized fatigue, mild shortness of breath during exertion, nasal congestion, and intermittent
headaches.
, The patient denies chest pain, hemoptysis, nausea, vomiting, or recent travel. He states that
several coworkers recently experienced upper respiratory symptoms. He has attempted over-
the-counter cough suppressants with minimal relief.
Associated symptoms include:
• Mild fever
• Chills
• Decreased appetite
• Sore throat initially, now improved
Pain assessment:
• Mild throat irritation
• Rates discomfort 2/10
Past Medical History
• Seasonal allergic rhinitis
• No chronic pulmonary disease
• No asthma history
• No hypertension or diabetes
Surgical History
• Appendectomy at age 16