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NURS 6512 Week 7 i-Human Case Study - 28-Year-Dld Male with Cough and Fatigue | Complete Assessment, Diagnosis & SOAP Note (UPDATED 2026 VERSION) A OF OU ANN Case Instructions. ~ x, » Weal CASE PLAT TU AAD FRONT . an ae eam Cane Ween 67 i” fa — Yous ; STUDY) -- Complete SOAP Note, Clinical Assessment, Differential Diagnosis & Evidence-Based Management (UPDATED 2026 VERSION) 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 eat, which has sometimes caused mild nasal congestion. |, HISTORY OF PRESENT ILLNESS (HPI) Pivotal Concents Category Question Response Aeeressed Key Ninaings co When oid the cough start? 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Complete SOAP Note, Clinical Assessment, Differential Diagnosis & Evidence-Based Management (UPDATED 2026 VERSION) 1. Patient Overview Demographics: 28-year-old male. Setting: Outpatient primary care clinic. Mode of Encounter: Scheduled appointment for persistent symptoms. Chief Complaint: "I've had this cough for about six months, and I'm just constantly tired." Context: A previously healthy young adult presenting with subacute-to-chronic respiratory and constitutional symptoms, requiring a systematic approach to differentiate between benign etiologies and potentially serious underlying conditions. 2. Subjective Data (History & Interview Findings) History of Present Illness (HPI): o Onset & Duration: Cough began approximately six months ago, insidious in onset. Fatigue noted concurrently, worsening progressively. o Character of Cough: Described as dry, hacking, non- productive. No reported sputum production (no phlegm). o Timing & Modifying Factors: Cough is present throughout the day. No clear positional aggravating or relieving factors. Not consistently worse at night, but occasionally disrupts sleep. o Severity: Rated 5/10 in severity; frustrating and impacting daily life but not debilitating. « Review of Systems (ROS) - Comprehensive: o Constitutional: Reports significant, persistent fatigue. Denies fever, chills, night sweats, or unexplained weight loss. Appetite stable. o Respiratory: Denies shortness of breath (SOB), dyspnea on exertion (DOE), wheezing, chest pain, tightness, or hemoptysis (coughing up blood). Denies orthopnea or paroxysmal nocturnal dyspnea (PND). o Cardiovascular: Denies palpitations, chest pain, or syncope. o Gastrointestinal: Denies heartburn, acid reflux, regurgitation, abdominal pain, nausea, vomiting, or change in bowel habits. Denies melena or hematochezia. o EENT (Eyes, Ears, Nose, Throat): Denies rhinorrhea, post- nasal drip, sinus pressure, sore throat, or hoarseness. o Musculoskeletal: Denies joint pain, swelling, or myalgias. o Integumentary: Denies rashes, lesions, or changes in skin integrity. o Neurological: Denies headache, dizziness, paresthesia, or focal weakness. Fatigue is primary neurological concern. o Psychiatric: Denies depressed mood, anhedonia, or increased anxiety. Reports frustration and irritability due to persistent symptoms. ° ° ° Sexual History: Monogamous heterosexual relationship. Uses condoms inconsistently. Diet & Exercise: Reports a standard American diet, low fruit/vegetable intake. Minimal structured exercise due to fatigue. Psychosocial: Lives with girlfriend. Describes moderate work-related stress. Good social support system. Family History: ° ° Father: Hypertension, diagnosed at age 55. Mother: Hypothyroidism, diagnosed at age 48. Paternal Grandfather: Coronary Artery Disease (CAD), MI at 70. Maternal Grandmother: Rheumatoid Arthritis. No known family history of lung cancer, cystic fibrosis, alpha-1 antitrypsin deficiency, or tuberculosis. Patient Perspective: "| just want to know what's causing this. It's affecting my work and | don't have energy for anything anymore. I'm worried it could be something serious, like cancer." 3. Objective Data (Physical Exam & Findings) General Appearance: Alert, oriented x4, cooperative. Appears slightly fatigued but in no acute distress. Well-groomed. Vital Signs: ° ° Blood Pressure: 118/76 mm Hg (seated, right arm). Heart Rate: 68 beats per minute, regular rhythm. ° Respiratory Rate: 14 breaths per minute, unlabored. o Temperature: 98.6°F (37.0°C), oral. ° ° SpO2: 99% on room air. Pain: 0/10. « Anthropometrics: ° ° ° Height: 70 inches (178 cm). Weight: 165 Ibs (75 kg). Body Mass Index (BMI): 23.7 kg/m? (Normal range). « Focused Physical Exam Findings: ° HEENT: Normocephalic, atraumatic. Conjunctivae pink, sclera anicteric. Oropharynx clear, no erythema, exudate, or post-nasal drip visible. Mucous membranes moist. Neck: Supple, no lymphadenopathy (no cervical, supraclavicular, or axillary nodes palpable). Thyroid non- enlarged, smooth, without nodules. Cardiovascular: Regular rate and rhythm (RRR). S1 and S2 normal, no murmurs, rubs, or gallops. Peripheral pulses (radial, pedal) 2+ and symmetric. No jugular venous distension (JVD). Lungs: Clear to auscultation bilaterally in all lung fields (anterior, posterior, lateral). No wheezes, rales, rhonchi, or stridor. Good bilateral air entry and expansion. No dullness to percussion. Tactile fremitus normal and symmetric. Differential Diagnoses (Prioritized): 1. Upper Airway Cough Syndrome (UACS) / Postnasal Drip: A leading cause of chronic cough. Symptoms can be subtle; patient may not perceive "drip." Fatigue may be from sleep disruption. Exam lacks clear sinonasal signs, but this remains high on the list due to prevalence. . Cough-Variant Asthma (CVA): A classic presentation of asthma where cough is the sole or predominant symptom. History of childhood asthma is a significant risk factor. Physical exam and spirometry can be normal between episodes. A top contender. . Gastroesophageal Reflux Disease (GERD)-Related Cough: Micro-aspiration or vagal reflex can cause chronic cough without typical heartburn ("silent reflux"). Lack of Gl symptoms lowers but does not exclude. . Post-Infectious Cough: Following a viral URI, airway inflammation and hyper-responsiveness can persist for weeks (often called "pertussis-like" syndrome). Timeline (6 months) makes a simple viral etiology less likely, but other pathogens (e.g., Mycoplasma, Chlamydia pneumoniae) can cause protracted symptoms. . Angiotensin-Converting Enzyme Inhibitor (ACE-I) Cough: Not applicable, as patient is on no medications. . Chronic Bronchitis: Very unlikely in a never-smoker without sputum production. . Serious/Emergent Conditions (Must RULE OUT): Pulmonary Tuberculosis (TB): Low probability given lack of constitutional symptoms (fever, night sweats, weight loss), no risk factors (no travel, no known exposure), and normal exam. » Lung Cancer/Neoplasm: Extremely low probability in a 28-year-old never-smoker without alarm symptoms (hemoptysis, weight loss, focal findings). However, it must remain in the differential until more common causes are ruled out. Interstitial Lung Disease (ILD): Would expect findings like inspiratory crackles or clubbing. Highly unlikely. Heart Failure: No orthopnea, PND, edema, JVD, or abnormal cardiopulmonary exam. Ruled out. Obstructive Sleep Apnea (OSA): Could explain fatigue and possibly cough (from airway irritation). No snoring or witnessed apneas reported, but BMI is normal and risk is lower. Final Working Diagnosis (Pending Diagnostics): o Chronic Cough, Etiology Undetermined. Most likely underlying etiologies, in order of probability: 1) Cough- Variant Asthma, 2) Upper Airway Cough Syndrome, 3) Gastroesophageal Reflux Disease. A stepwise diagnostic and therapeutic approach is warranted. 5. Diagnostic Testing Plan (Evidence-Based & Rationale) First-Line, Point-of-Care Testing: intranasal corticosteroid (e.g., Fluticasone) for 2- 3 weeks. 2. Trial for CVA: If no response to UASC trial, initiate a medium-dose Inhaled Corticosteroid (ICS) (e.g., Fluticasone 110 mcg 2 puffs BID) for 4-6 weeks. A significant reduction in cough confirms the diagnosis. 3. Trial for GERD: If no response to above, initiate a high-dose Proton Pump Inhibitor (PPI) (e.g., Omeprazole 40mg BID) for 8-12 weeks, taken 30- 60 minutes before meals. Lifestyle modifications concurrently. o If fatigue remains predominant and unexplained: Thyroid Stimulating Hormone (TSH): Strong family history of hypothyroidism makes this essential. » Vitamin D, B12 Levels: Common nutritional deficiencies linked to fatigue. Screening for Depression/Anxiety (PHQ-9, GAD-7): To evaluate for a psychological component, though patient denies mood symptoms. » Consider Sleep Study: If fatigue is severe and OSA risk factors emerge or if trials for cough fail. 6. SOAP Note « S (Subjective): "I've had this dry cough for about six months, and I'm just constantly tired." Cough is dry, non-productive, present daily. Rates severity 5/10. Significant fatigue affecting work and exercise. Denies SOB, DOE, chest pain, fever, night sweats, weight loss, heartburn, post-nasal drip, or hemoptysis. PMH: Childhood asthma. Meds: OTC cough syrup PRN. Social: Never smoker, social EtOH, sedentary job. Concerned about serious cause. « O (Objective): ° ° ° ° Vitals: BP 118/76, HR 68, RR 14, Temp 98.6°F, SpO2 99% RA. Gen: Well-appearing, NAD. HEENT: Oropharynx clear, no post-nasal drip. Cv: RRR, no murmurs, no JVD. Lungs: CTA bilaterally, no adventitious sounds. Abd: Soft, NT/ND. Ext: No clubbing, cyanosis, or edema. « A (Assessment): ° ° ° Primary Problem: Chronic Cough, etiology undetermined (ROS). Secondary Problem: Fatigue (R53.83). Differential Diagnoses (Prioritized): 1. Cough-Variant Asthma. 2. Upper Airway Cough Syndrome. 3. Gastroesophageal Reflux Disease (silent). 7. Evidence-Based Management Plan « Phase 1: Diagnosis & Initial Therapeutic Trial (Weeks 1-4) o Actions: Perform/obtain CXR, spirometry, CBC, BMP, TSH. Initiate UACS trial with intranasal corticosteroids. o Rationale: Addresses the most common causes first using a safe, low-risk intervention. Awaits objective data to guide next steps. o Patient Communication: "We're starting with a medication for a possible sinus drip you might not feel, as this is the most common cause. We'll get some basic tests to ensure nothing else is going on." « Phase 2: Evaluation & Second Therapeutic Trial (Weeks 4-10) o Scenario A (UACS Trial Successful): Cough resolved/minimized. Management: Continue nasal steroid for a total of 3 months, then attempt to taper. Reassess fatigue; if persists, pursue fatigue-specific workup (full thyroid panel, vitamins, sleep hygiene, PHQ-9). o Scenario B (UACS Trial Unsuccessful, Spirometry Normal): Actions: Begin CVA trial with medium-dose ICS (e.g., Fluticasone 110 mcg BID) for 6 weeks. Consider methacholine challenge if available to confirm before starting long-term medication. o Scenario B Rationale: CVA is the next most likely diagnosis. An empiric ICS trial is diagnostic and therapeutic. « Phase 3: Third Therapeutic Trial & Specialist Referral (Weeks 10- 20+) Scenario C (ICS Trial Unsuccessful): Actions: Begin GERD trial with high-dose PPI (e.g., Omeprazole 40mg BID) for 8- 12 weeks. Emphasize strict lifestyle modifications: elevate head of bed, avoid late meals, identify and avoid trigger foods (caffeine, chocolate, spicy/fatty foods). Scenario C Rationale: Silent GERD is a common culprit. A prolonged, high-dose trial is necessary to assess efficacy. Scenario D (All Empiric Trials Fail): Actions: Refer to Pulmonology and/or Gastroenterology for further evaluation. Pulmonology may consider bronchoscopy, high- resolution CT chest. GI may consider endoscopy or pH/impedance monitoring. Scenario D Rationale: Specialist input is required for uncommon causes (e.g., idiopathic cough, neuropathic cough, rare interstitial diseases). 8. Patient Education Condition Explained: "A cough lasting this long has a short list of common causes, most of which are treatable. We will work throu sign." gh them step-by-step. Your normal exam is a very reassuring Diagnostic Plan Rationale: Explain the purpose of each test: CXR is a "big picture" check, spirometry tests lung function, blood tests rule out anemia or thyroid issues. Therapeutic Trial Process: Emphasize that diagnosis may be made by seeing which treatment works. Stress the importance of o If cough resolves, discuss prevention of recurrence. « Specialist Referral Timeline: Referral to Pulmonology/Gl if no improvement after 12-16 weeks of structured empiric therapy. « Prognosis: o Excellent. The vast majority of chronic cough cases in otherwise healthy young adults have a treatable etiology (UACS, CVA, GERD). With a systematic approach, a specific diagnosis and effective treatment can be found in over 90% of cases. o Fatigue is expected to improve as the underlying cause of the cough is treated and sleep improves. If fatigue persists independently, it will be investigated as a separate but potentially related issue. 10. Conclusion This case of a 28-year-old male with a chronic cough and fatigue exemplifies the clinical reasoning required in primary care for a common yet potentially complex presentation. The absence of "red flag" symptoms and a completely normal physical exam are reassuring but do not negate the need for a structured, evidence-based diagnostic algorithm. The cornerstone of management is the sequential, empiric therapeutic trial targeting the most prevalent etiologies—UACS, CVA, and GERD—guided by judicious initial testing. Effective patient education regarding this process is crucial for adherence and managing expectations. This systematic approach maximizes the likelihood of efficiently identifying the underlying cause, implementing effective treatment, and alleviating the patient's symptoms, ultimately restoring his quality of life. The case underscores the importance of moving beyond a purely symptomatic treatment approach to a diagnostic one, even in the absence of alarming clinical findings. This response is Al-generated, for reference only. Lt | 
