Evaluation of
Cough and Fatigue 28-Year-Old Male
CLASS 6512 latest 2025.
, i- Human Case Week #7
Patient: 28-year-old male
Height: 5'7" (170 cm)
Weight: 150 lb (68.2 kg)
Reason for Encounter: Cough and fatigue
Location: Outpatient clinic (x-ray, ECG, and laboratory capabilities available)
1. HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 28-year-old man who presents with a 10-day history of cough
and generalized fatigue. The cough started gradually and has been mostly dry,
occasionally producing a small amount of clear sputum. He reports that the
cough is worse at night and sometimes after mild exertion. The fatigue began
around the same time as the cough.
He had mild sore throat and low-grade fever (99–100°F) during the first few
days, both of which resolved. He denies chills, chest pain, dyspnea, wheezing, or
hemoptysis. No orthopnea, paroxysmal nocturnal dyspnea, or leg swelling. He
denies weight loss, night sweats, or appetite changes.
He works in an open office setting where several colleagues recently
experienced colds or coughs. He has not traveled recently and denies known TB
exposure. He has not been around anyone with pneumonia.
Functional impact: He reports feeling tired at work and needing to take breaks
due to low energy but continues to perform daily activities.