i-Human Case Study Week 7: 28-Year-Old Male
with Cough and Fatigue | Complete Assessment,
Diagnosis & SOAP Note | NURS 6512 Walden
University (2025)
, i-Human Case Study: 28-Year-Old Male with Cough and Fatigue
Course: NURS 6512 – Advanced Health Assessment
Institution: Walden University
Week 7 Comprehensive Case Study
Introduction
The case is on J.S., a 28-year-old male presenting to the outpatient clinic with 10
days' cough and fatigue. The purpose of this assessment is to apply sophisticated
health-assessment, diagnostic-reasoning, and evidence-based management skills to
establish likely etiologies, rule out life-threatening possibilities, and initiate a
proper treatment and follow-up plan.
Subjective Data
J.S. has a cough that began 10 days ago following an acute mild upper-respiratory
infection. The cough was dry initially but has been intermittently productive with
white sputum. He was febrile for the first three days but subsequently afebrile. He
does not have hemoptysis, chest pain, or shortness of breath on rest. The fatigue
has progressively bothered him, impacting work but not sleep or post-exertional
malaise. He smokes intermittently (about 5 pack-years). He denies travel, TB
exposure, or chronic disease.
Relevant negatives: no history of wheezing, no reflux symptoms, and no recent
history of antibiotic use.
with Cough and Fatigue | Complete Assessment,
Diagnosis & SOAP Note | NURS 6512 Walden
University (2025)
, i-Human Case Study: 28-Year-Old Male with Cough and Fatigue
Course: NURS 6512 – Advanced Health Assessment
Institution: Walden University
Week 7 Comprehensive Case Study
Introduction
The case is on J.S., a 28-year-old male presenting to the outpatient clinic with 10
days' cough and fatigue. The purpose of this assessment is to apply sophisticated
health-assessment, diagnostic-reasoning, and evidence-based management skills to
establish likely etiologies, rule out life-threatening possibilities, and initiate a
proper treatment and follow-up plan.
Subjective Data
J.S. has a cough that began 10 days ago following an acute mild upper-respiratory
infection. The cough was dry initially but has been intermittently productive with
white sputum. He was febrile for the first three days but subsequently afebrile. He
does not have hemoptysis, chest pain, or shortness of breath on rest. The fatigue
has progressively bothered him, impacting work but not sleep or post-exertional
malaise. He smokes intermittently (about 5 pack-years). He denies travel, TB
exposure, or chronic disease.
Relevant negatives: no history of wheezing, no reflux symptoms, and no recent
history of antibiotic use.
