i-Human Case Study: 28-Year-Old Male with Cough and Fatigue
Chief Complaint: Cough and Fatigue
History of Present Illness (HPI)
• The patient is a 28-year-old male presenting with a 2-week history of persistent cough
accompanied by fatigue.
• The cough began gradually following a mild upper respiratory infection. It is mostly dry,
though occasionally produces a small amount of clear sputum.
• The patient experienced mild fever for two days at onset, which resolved without treatment.
• He denies hemoptysis, chest pain, significant sputum production, or weight loss.
• The cough is sometimes worse at night and occasionally disturbs his sleep.
• He notes mild shortness of breath when climbing stairs but denies wheezing at rest.
• He has tried over-the-counter cough syrup and paracetamol with limited relief.
• His roommate had a cold about two weeks ago, which preceded the onset of his symptoms.
• The patient occasionally vapes (3–4 times per week) and owns a cat, which has sometimes
caused mild nasal congestion.
,Comprehensive Case Study: 28-Year-Old Male with Cough and Fatigue
,
Chief Complaint: Cough and Fatigue
History of Present Illness (HPI)
• The patient is a 28-year-old male presenting with a 2-week history of persistent cough
accompanied by fatigue.
• The cough began gradually following a mild upper respiratory infection. It is mostly dry,
though occasionally produces a small amount of clear sputum.
• The patient experienced mild fever for two days at onset, which resolved without treatment.
• He denies hemoptysis, chest pain, significant sputum production, or weight loss.
• The cough is sometimes worse at night and occasionally disturbs his sleep.
• He notes mild shortness of breath when climbing stairs but denies wheezing at rest.
• He has tried over-the-counter cough syrup and paracetamol with limited relief.
• His roommate had a cold about two weeks ago, which preceded the onset of his symptoms.
• The patient occasionally vapes (3–4 times per week) and owns a cat, which has sometimes
caused mild nasal congestion.
,Comprehensive Case Study: 28-Year-Old Male with Cough and Fatigue
,
