,Patient Information
Name: Marvin Webster
Age: 18 years old
Gender: Male
Setting: Outpatient Student Health Clinic
Chief Complaint: “I’m exhausted, and I have a cough that’s
keeping me up at night.”
Reason for Encounter: Fatigue and cough
History of Present Illness (HPI)Narrative: Marvin Webster, an 18-year-
old Caucasian male college freshman, presents to the student health
clinic with a 4-day history of fatigue, a dry nonproductive cough, and
generalized body aches. He describes his fatigue as overwhelming (7/10
severity), stating, “I feel like I can’t get out of bed,” which has led to
missing classes and difficulty studying. The cough is persistent, worse at
,night, and disrupts sleep, exacerbating his exhaustion. Marvin also
reports a sore throat (6/10 severity, described as “scratchy and
painful”) and a mild frontal headache (3/10 severity), both starting
concurrently with his other symptoms. He has tried ibuprofen 400 mg
for headache and body aches, which provides partial relief for the
headache but not the sore throat or fatigue. He denies fever, chills,
night sweats, sputum production, hemoptysis, shortness of breath, or
chest pain. Marvin notes his roommate had similar symptoms (cough,
fatigue) 1 week ago, suggesting a possible sick contact. He denies
recent travel, exposure to tuberculosis, or other environmental hazards
(e.g., mold, toxins).Marvin reports a flu-like illness 2 weeks ago that
resolved without medical attention. He denies nausea, vomiting,
diarrhea, weight loss, or neurological symptoms (e.g., dizziness,
weakness). His medical history includes mild childhood asthma, with no
recent exacerbations or medication use. He takes ibuprofen PRN but no
prescription medications. Marvin is unsure of his immunization status,
confirming he did not receive the 2024–2025 influenza vaccine or a
, recent COVID-19 booster. He is distressed about falling behind
academically, as his symptoms interfere with attending lectures and
completing assignments, and he worries about the impact on his
grades.Explanation: The HPI is critical for acute respiratory complaints
to identify the etiology and guide diagnostics. Marvin’s acute onset of
fatigue, dry cough, sore throat, headache, and myalgias, combined with
a sick contact in a dormitory setting, strongly suggests a viral infection,
such as influenza or a viral upper respiratory infection (URI). The
absence of fever (subjective), productive cough, or respiratory distress
lowers suspicion for bacterial pneumonia or asthma exacerbation. His
unvaccinated status and college environment increase the risk of
contagious viral illnesses. The prior flu-like illness raises the possibility
of a recurrent or secondary infection, though resolved symptoms
suggest it is unrelated. Addressing Marvin’s academic concerns through
clear communication and support is essential to reduce stress and
promote treatment adherence, aligning with patient-centered care
principles in primary care.
Name: Marvin Webster
Age: 18 years old
Gender: Male
Setting: Outpatient Student Health Clinic
Chief Complaint: “I’m exhausted, and I have a cough that’s
keeping me up at night.”
Reason for Encounter: Fatigue and cough
History of Present Illness (HPI)Narrative: Marvin Webster, an 18-year-
old Caucasian male college freshman, presents to the student health
clinic with a 4-day history of fatigue, a dry nonproductive cough, and
generalized body aches. He describes his fatigue as overwhelming (7/10
severity), stating, “I feel like I can’t get out of bed,” which has led to
missing classes and difficulty studying. The cough is persistent, worse at
,night, and disrupts sleep, exacerbating his exhaustion. Marvin also
reports a sore throat (6/10 severity, described as “scratchy and
painful”) and a mild frontal headache (3/10 severity), both starting
concurrently with his other symptoms. He has tried ibuprofen 400 mg
for headache and body aches, which provides partial relief for the
headache but not the sore throat or fatigue. He denies fever, chills,
night sweats, sputum production, hemoptysis, shortness of breath, or
chest pain. Marvin notes his roommate had similar symptoms (cough,
fatigue) 1 week ago, suggesting a possible sick contact. He denies
recent travel, exposure to tuberculosis, or other environmental hazards
(e.g., mold, toxins).Marvin reports a flu-like illness 2 weeks ago that
resolved without medical attention. He denies nausea, vomiting,
diarrhea, weight loss, or neurological symptoms (e.g., dizziness,
weakness). His medical history includes mild childhood asthma, with no
recent exacerbations or medication use. He takes ibuprofen PRN but no
prescription medications. Marvin is unsure of his immunization status,
confirming he did not receive the 2024–2025 influenza vaccine or a
, recent COVID-19 booster. He is distressed about falling behind
academically, as his symptoms interfere with attending lectures and
completing assignments, and he worries about the impact on his
grades.Explanation: The HPI is critical for acute respiratory complaints
to identify the etiology and guide diagnostics. Marvin’s acute onset of
fatigue, dry cough, sore throat, headache, and myalgias, combined with
a sick contact in a dormitory setting, strongly suggests a viral infection,
such as influenza or a viral upper respiratory infection (URI). The
absence of fever (subjective), productive cough, or respiratory distress
lowers suspicion for bacterial pneumonia or asthma exacerbation. His
unvaccinated status and college environment increase the risk of
contagious viral illnesses. The prior flu-like illness raises the possibility
of a recurrent or secondary infection, though resolved symptoms
suggest it is unrelated. Addressing Marvin’s academic concerns through
clear communication and support is essential to reduce stress and
promote treatment adherence, aligning with patient-centered care
principles in primary care.
