IHUMAN CASE WEEK #7 | 28Y/O 170CM &68.2KG | REASON FOR ENCOUNTER COUGH AND FATIGUE |
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LATEST EXAM UPDATE
x x x
i- Human Case Week #7: 28-Year-Old Male – “Cough and Fatigue”
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Setting: OutpatientClinic(withX-ray,ECG,andlaboratory capabilities)
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Student Nurse Case Report
x x x
, SOAP Note x
S – Subjective
x x
ChiefComplaint (CC): x x
“I’ve been coughing and feeling tired for about two weeks.”
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History of Present Illness (HPI): x x x x
Mr. Daniel Parker (pseudonym), a 28-year-old male, presents with a persistent productive cough for two
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weeks associated with fatigue and occasional shortness of breath on exertion. He describes the sputum
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as yellowish, moderate in amount, and denies any blood. He had mild fever and chills during the first few
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days but no chest pain, night sweats, or weight loss. No history of asthma or allergies.
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He was recently recovering from a cold.
x x x x x x
Past Medical History(PMH):
x x x
• No chronic illnesses reported
x x x
• Up-to-date on immunizations x x
Medications:
• Occasionalparacetamol forfever x x x
• Over-the-counter cough syrup (self-started) x x x
Allergies: None known x x
FamilyHistory(FH): x x
• Non-contributory; no asthma or TB x x x x
SocialHistory (SH): x x
• Non-smoker,socialalcohol useonly x x x x
• Works as a gym trainer; no recent travelx x x x x x x
• Lives with roommates x x
Review of Systems(ROS): x x x
• Respiratory: Cough with sputum, fatigue, mild dyspnea on exertion x x x x x x x x
• Constitutional: Felt feverish initially, now resolved x x x x x
• Cardiac: No chest pain or palpitations x x x x x
• GI: Normal appetite
x x
• Neuro: Tiredness but no weakness x x x x
x x x x x x x x x x x x x x x
LATEST EXAM UPDATE
x x x
i- Human Case Week #7: 28-Year-Old Male – “Cough and Fatigue”
x x x x x x x x x
Setting: OutpatientClinic(withX-ray,ECG,andlaboratory capabilities)
x x x x x x x x x
Student Nurse Case Report
x x x
, SOAP Note x
S – Subjective
x x
ChiefComplaint (CC): x x
“I’ve been coughing and feeling tired for about two weeks.”
x x x x x x x x x
History of Present Illness (HPI): x x x x
Mr. Daniel Parker (pseudonym), a 28-year-old male, presents with a persistent productive cough for two
x x x x x x x x x x x x x x
weeks associated with fatigue and occasional shortness of breath on exertion. He describes the sputum
x x x x x x x x x x x x x x x
as yellowish, moderate in amount, and denies any blood. He had mild fever and chills during the first few
x x x x x x x x x x x x x x x x x x x
days but no chest pain, night sweats, or weight loss. No history of asthma or allergies.
x x x x x x x x x x x x x x x x
He was recently recovering from a cold.
x x x x x x
Past Medical History(PMH):
x x x
• No chronic illnesses reported
x x x
• Up-to-date on immunizations x x
Medications:
• Occasionalparacetamol forfever x x x
• Over-the-counter cough syrup (self-started) x x x
Allergies: None known x x
FamilyHistory(FH): x x
• Non-contributory; no asthma or TB x x x x
SocialHistory (SH): x x
• Non-smoker,socialalcohol useonly x x x x
• Works as a gym trainer; no recent travelx x x x x x x
• Lives with roommates x x
Review of Systems(ROS): x x x
• Respiratory: Cough with sputum, fatigue, mild dyspnea on exertion x x x x x x x x
• Constitutional: Felt feverish initially, now resolved x x x x x
• Cardiac: No chest pain or palpitations x x x x x
• GI: Normal appetite
x x
• Neuro: Tiredness but no weakness x x x x
