I HUMAN CASE STUDY CHANA KUMAR 86 YEAR OLD
FEMALE REASON FOR ENCOUNTER PERSISTENT FATIGUE
FOR 2MONTHS WITH FULL SOAP NOTE REAL 2025!!
LATEST
Reason for Encounter
Chana Kumar, 86-year-old female, presents with persistent fatigue for the past 2 months, which has
been gradually worsening.
History of Present Illness (HPI)
• Onset: Fatigue started approximately 2 months ago, gradual onset.
• Duration: Persistent, most days of the week.
• Quality: Describes fatigue as “constant tiredness,” not relieved by rest.
, • Severity: Moderate to severe, limiting daily activities.
• Aggravating factors: Physical activity worsens fatigue.
• Relieving factors: Short naps temporarily improve symptoms.
• Associated symptoms:
o Unintentional weight loss (~5 lbs in 2 months)
o Mild shortness of breath on exertion
o Occasional dizziness
o Decreased appetite
o No fever, chills, or night sweats
• Past medical history: Hypertension, osteoarthritis
• Medications: Lisinopril, acetaminophen as needed
• Allergies: No known drug allergies
• Family history: Mother had hypothyroidism, father died of heart disease
• Social history: Lives alone, retired teacher, non-smoker, occasional alcohol
Review of Systems (ROS)
• General: Fatigue, weight loss, decreased appetite
• Cardiovascular: Mild exertional dyspnea, no chest pain
• Respiratory: Occasional shortness of breath
• GI: Mild constipation, no nausea/vomiting
• GU: No dysuria
• Musculoskeletal: Some stiffness in knees, no new weakness
• Neuro: Mild dizziness, no focal deficits, no confusion
• Skin: No rashes or lesions
• Endocrine: No polydipsia/polyuria
Physical Exam
• Vitals: BP 138/78 mmHg, HR 82 bpm, RR 18, Temp 36.7°C, O2 sat 96%
• General: Alert, appears fatigued, well-nourished
, • HEENT: Pale conjunctiva, no icterus, oral mucosa dry
• Cardiac: Regular rate and rhythm, no murmurs, no edema
• Respiratory: Clear breath sounds bilaterally, no wheezes or crackles
• Abdomen: Soft, non-tender, no hepatosplenomegaly
• Musculoskeletal: Mild knee osteoarthritis, full ROM, no joint swelling
• Neurologic: Oriented ×3, normal strength, no focal deficits
• Skin: Slight pallor, no lesions
Assessment
Primary problem: Chronic fatigue in an elderly patient.
Differential diagnosis:
1. Anemia (iron deficiency, B12 deficiency, chronic disease) – pallor and fatigue suggest anemia.
2. Hypothyroidism – fatigue, weight loss, and family history.
3. Depression – common in elderly, consider given fatigue and decreased appetite.
4. Chronic heart failure – mild dyspnea, age risk factor.
5. Malignancy – unintentional weight loss concerning.
6. Medication-related fatigue – consider antihypertensives or polypharmacy.
Most likely: Anemia or hypothyroidism based on presentation.
Plan
Diagnostics:
• CBC with differential (evaluate for anemia)
• CMP (electrolytes, renal/hepatic function)
• TSH, free T4 (evaluate for hypothyroidism)
• Vitamin B12 and folate levels
• Iron studies (ferritin, iron, TIBC)
• UA (rule out UTI)
• EKG (baseline cardiac status)
• Consider CXR if dyspnea worsens
FEMALE REASON FOR ENCOUNTER PERSISTENT FATIGUE
FOR 2MONTHS WITH FULL SOAP NOTE REAL 2025!!
LATEST
Reason for Encounter
Chana Kumar, 86-year-old female, presents with persistent fatigue for the past 2 months, which has
been gradually worsening.
History of Present Illness (HPI)
• Onset: Fatigue started approximately 2 months ago, gradual onset.
• Duration: Persistent, most days of the week.
• Quality: Describes fatigue as “constant tiredness,” not relieved by rest.
, • Severity: Moderate to severe, limiting daily activities.
• Aggravating factors: Physical activity worsens fatigue.
• Relieving factors: Short naps temporarily improve symptoms.
• Associated symptoms:
o Unintentional weight loss (~5 lbs in 2 months)
o Mild shortness of breath on exertion
o Occasional dizziness
o Decreased appetite
o No fever, chills, or night sweats
• Past medical history: Hypertension, osteoarthritis
• Medications: Lisinopril, acetaminophen as needed
• Allergies: No known drug allergies
• Family history: Mother had hypothyroidism, father died of heart disease
• Social history: Lives alone, retired teacher, non-smoker, occasional alcohol
Review of Systems (ROS)
• General: Fatigue, weight loss, decreased appetite
• Cardiovascular: Mild exertional dyspnea, no chest pain
• Respiratory: Occasional shortness of breath
• GI: Mild constipation, no nausea/vomiting
• GU: No dysuria
• Musculoskeletal: Some stiffness in knees, no new weakness
• Neuro: Mild dizziness, no focal deficits, no confusion
• Skin: No rashes or lesions
• Endocrine: No polydipsia/polyuria
Physical Exam
• Vitals: BP 138/78 mmHg, HR 82 bpm, RR 18, Temp 36.7°C, O2 sat 96%
• General: Alert, appears fatigued, well-nourished
, • HEENT: Pale conjunctiva, no icterus, oral mucosa dry
• Cardiac: Regular rate and rhythm, no murmurs, no edema
• Respiratory: Clear breath sounds bilaterally, no wheezes or crackles
• Abdomen: Soft, non-tender, no hepatosplenomegaly
• Musculoskeletal: Mild knee osteoarthritis, full ROM, no joint swelling
• Neurologic: Oriented ×3, normal strength, no focal deficits
• Skin: Slight pallor, no lesions
Assessment
Primary problem: Chronic fatigue in an elderly patient.
Differential diagnosis:
1. Anemia (iron deficiency, B12 deficiency, chronic disease) – pallor and fatigue suggest anemia.
2. Hypothyroidism – fatigue, weight loss, and family history.
3. Depression – common in elderly, consider given fatigue and decreased appetite.
4. Chronic heart failure – mild dyspnea, age risk factor.
5. Malignancy – unintentional weight loss concerning.
6. Medication-related fatigue – consider antihypertensives or polypharmacy.
Most likely: Anemia or hypothyroidism based on presentation.
Plan
Diagnostics:
• CBC with differential (evaluate for anemia)
• CMP (electrolytes, renal/hepatic function)
• TSH, free T4 (evaluate for hypothyroidism)
• Vitamin B12 and folate levels
• Iron studies (ferritin, iron, TIBC)
• UA (rule out UTI)
• EKG (baseline cardiac status)
• Consider CXR if dyspnea worsens
