I-HUMAN CASE WEEK 7: EVALUATION OF COUGH
AND FATIGUE – 28-YEAR-OLD MALE SOAP NOTE
(COMMUNITY-ACQUIRED PNEUMONIA)
,Patient Summary:
Age/Sex: 28-year-old male
Height/Weight: 5’7’’ (170 cm), 150 lb (68.2 kg)
Chief Complaint: Cough and fatigue
Location: Outpatient clinic — equipped with X-ray, ECG, and
laboratory testing
Case Instructions (H&P+Dx Case Play Setup and Instructions):
Mode:
o The assignment is in Learning Mode.
o Feedback is provided after each section submission.
o A final performance overview is generated after completing
the case.
Attempts Available:
o You are permitted one attempt for this assignment.
� History of Present Illness (HPI)
Chief Complaint:
―I’ve been feeling tired and have had a cough for about two weeks.‖
HPI Details:
Onset: About 2 weeks ago
Course: Started as a mild dry cough; now more productive with
yellowish sputum.
Duration: Persistent; occurs throughout the day, worse at night.
Associated Symptoms:
o Fatigue, mild shortness of breath on exertion
o Low-grade fever (100.4°F / 38°C)
o Occasional chest tightness
Aggravating Factors: Physical activity, lying down
, Relieving Factors: Rest and fluids help slightly
Severity: Moderate; interfering with work and sleep
Previous Episodes: None reported
Sick Contacts: Roommate recently had a ―chest cold‖
COVID/Flu exposure: Denies recent exposure or travel
� Past Medical History
No chronic medical conditions reported
No history of asthma, allergies, or heart disease
No hospitalizations or surgeries
� Medications
Occasional over-the-counter acetaminophen for fever
No prescription medications
� Allergies
NKDA (No Known Drug Allergies)
��� Family History
Father: Hypertension
Mother: Healthy
No family history of respiratory illness or cardiac disease
� Social History
AND FATIGUE – 28-YEAR-OLD MALE SOAP NOTE
(COMMUNITY-ACQUIRED PNEUMONIA)
,Patient Summary:
Age/Sex: 28-year-old male
Height/Weight: 5’7’’ (170 cm), 150 lb (68.2 kg)
Chief Complaint: Cough and fatigue
Location: Outpatient clinic — equipped with X-ray, ECG, and
laboratory testing
Case Instructions (H&P+Dx Case Play Setup and Instructions):
Mode:
o The assignment is in Learning Mode.
o Feedback is provided after each section submission.
o A final performance overview is generated after completing
the case.
Attempts Available:
o You are permitted one attempt for this assignment.
� History of Present Illness (HPI)
Chief Complaint:
―I’ve been feeling tired and have had a cough for about two weeks.‖
HPI Details:
Onset: About 2 weeks ago
Course: Started as a mild dry cough; now more productive with
yellowish sputum.
Duration: Persistent; occurs throughout the day, worse at night.
Associated Symptoms:
o Fatigue, mild shortness of breath on exertion
o Low-grade fever (100.4°F / 38°C)
o Occasional chest tightness
Aggravating Factors: Physical activity, lying down
, Relieving Factors: Rest and fluids help slightly
Severity: Moderate; interfering with work and sleep
Previous Episodes: None reported
Sick Contacts: Roommate recently had a ―chest cold‖
COVID/Flu exposure: Denies recent exposure or travel
� Past Medical History
No chronic medical conditions reported
No history of asthma, allergies, or heart disease
No hospitalizations or surgeries
� Medications
Occasional over-the-counter acetaminophen for fever
No prescription medications
� Allergies
NKDA (No Known Drug Allergies)
��� Family History
Father: Hypertension
Mother: Healthy
No family history of respiratory illness or cardiac disease
� Social History
