i-Human Week 7 Case: 28-Year-Old Male –
Persistent Cough and Fatigue | NURS 6512
Comprehensive Assessment, Diagnosis &
Treatment Plan (2025)
,28-Year-Old Male with Cough and Fatigue
Course: NURS 6512 – Advanced Health Assessment
University: Walden University
Year: 2025
Step 1 – Reason for Encounter / Chief Complaint
“I’ve had this cough for about three weeks, and I’m feeling tired all the time.”
Explanation:
The chief complaint (CC) summarizes the patient’s main concern using his own
words.
It guides the focus of the entire visit—in this case, a subacute cough accompanied
by fatigue, prompting an evaluation of infectious, allergic, and respiratory causes.
Step 2 – History of Present Illness (HPI)
The patient is a 28-year-old man who reports a dry, non-productive cough
lasting three weeks. It began gradually after several coworkers experienced upper-
respiratory infections. He notes mild shortness of breath on exertion and evening
low-grade fevers.
He denies chest pain, hemoptysis, or weight loss. Over-the-counter cough syrup
gives minimal relief. No recent travel or sick family contacts.
Expanded rationale:
A stepwise HPI using the OLD CARTS mnemonic captures onset, duration, and
character of symptoms—essential for narrowing differentials. A subacute cough
(3–8 weeks) after URI exposure strongly suggests post-viral or atypical
infectious etiologies.
Step 3 – Past and Social History
Category Findings Explanation
, Category Findings Explanation
Rules out chronic pulmonary
Medical Seasonal allergies only
disease
Surgical Childhood tonsillectomy Non-contributory
Medications Cetirizine 10 mg daily May mask allergic component
Allergies NKDA Guides safe prescribing
Family Father – HTN; Mother – T2DM No genetic lung disorders
Non-smoker, social alcohol, office Reduces COPD risk; supports
Social
worker, exercises twice weekly post-viral etiology
Step 4 – Review of Systems (ROS)
• General: Fatigue, low-grade fevers; denies weight loss.
• HEENT: Nasal congestion; no sore throat.
• Respiratory: Dry cough, mild exertional dyspnea; denies wheeze,
hemoptysis.
• Cardiac: Denies chest pain or palpitations.
• GI/Skin: No nausea, vomiting, or rash.
Why: A targeted ROS identifies associated or systemic symptoms that refine the
differential and ensure no missed red-flag signs.
Step 5 – Objective Data (Physical Exam)
Vital Signs
BP 118/72 mm Hg | HR 84 bpm | RR 18 | Temp 99.3 °F (37.4 °C) | SpO₂ 97% RA |
BMI 22.1
Focused Exam
Persistent Cough and Fatigue | NURS 6512
Comprehensive Assessment, Diagnosis &
Treatment Plan (2025)
,28-Year-Old Male with Cough and Fatigue
Course: NURS 6512 – Advanced Health Assessment
University: Walden University
Year: 2025
Step 1 – Reason for Encounter / Chief Complaint
“I’ve had this cough for about three weeks, and I’m feeling tired all the time.”
Explanation:
The chief complaint (CC) summarizes the patient’s main concern using his own
words.
It guides the focus of the entire visit—in this case, a subacute cough accompanied
by fatigue, prompting an evaluation of infectious, allergic, and respiratory causes.
Step 2 – History of Present Illness (HPI)
The patient is a 28-year-old man who reports a dry, non-productive cough
lasting three weeks. It began gradually after several coworkers experienced upper-
respiratory infections. He notes mild shortness of breath on exertion and evening
low-grade fevers.
He denies chest pain, hemoptysis, or weight loss. Over-the-counter cough syrup
gives minimal relief. No recent travel or sick family contacts.
Expanded rationale:
A stepwise HPI using the OLD CARTS mnemonic captures onset, duration, and
character of symptoms—essential for narrowing differentials. A subacute cough
(3–8 weeks) after URI exposure strongly suggests post-viral or atypical
infectious etiologies.
Step 3 – Past and Social History
Category Findings Explanation
, Category Findings Explanation
Rules out chronic pulmonary
Medical Seasonal allergies only
disease
Surgical Childhood tonsillectomy Non-contributory
Medications Cetirizine 10 mg daily May mask allergic component
Allergies NKDA Guides safe prescribing
Family Father – HTN; Mother – T2DM No genetic lung disorders
Non-smoker, social alcohol, office Reduces COPD risk; supports
Social
worker, exercises twice weekly post-viral etiology
Step 4 – Review of Systems (ROS)
• General: Fatigue, low-grade fevers; denies weight loss.
• HEENT: Nasal congestion; no sore throat.
• Respiratory: Dry cough, mild exertional dyspnea; denies wheeze,
hemoptysis.
• Cardiac: Denies chest pain or palpitations.
• GI/Skin: No nausea, vomiting, or rash.
Why: A targeted ROS identifies associated or systemic symptoms that refine the
differential and ensure no missed red-flag signs.
Step 5 – Objective Data (Physical Exam)
Vital Signs
BP 118/72 mm Hg | HR 84 bpm | RR 18 | Temp 99.3 °F (37.4 °C) | SpO₂ 97% RA |
BMI 22.1
Focused Exam
