IHUMAN Practice Case Study: Mr. Marvin Webster 2024 UPDATED REVIEW

Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes”
“I feel awful, I’m exhausted. I have body aches
and just feel really tired.”
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Mr. Webster, an 18-yr-old male presented to the clinic with c
persistent dry cough, sore throat, right ear pain, fatigue, head
He reports he has exercised induced asthma which has been l
receive his annual flu vaccine.
Onset: Most symptoms appeared 1-2 days ago
Location: Mostly throat, Headache and Ear
Duration: Every day and symptoms have persisted since ons
Character: He reports 2/10 severity of ear pain which is non
sharp. Sore throat of 6-8/10 severity which is non radiating a
cut. Headache is mild and just annoying.
Aggravating/alleviating factors: Sore throat is aggravated b
swallowing.
Related symptoms: Fatigue and myalgia with onset of other
ago. Denies exposure to any sick people.
Treatments: He has tried ibuprofen for pain
Significance: He feels exhausted and he is missing class
PMHx child/adult
illness/hospitalizations/immunizations
Childhood exercised induced asthma with no
recent exacerbations.
No hospitalizations, trauma or other injuries
Immunizations: States his immunizations are
SurgHx type/when/why/complications
Never for Surgical history.
current for college. He has not received the Flu
vaccine this year.
FamHx
Grandparents(if known)/Parents/siblings/children
He has no knowledge of his grandparents
medical history.
Mother-age 58-Hypertension
Father-age 57-Healthy
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relati
Alcohol—Denies any recent alcohol intake, but occasionally
night after studying.
Tobacco—Denies any history of smoking, vaping, or other to
Denies Recreational drug use.
Relationships: Single
Full-time student, not planning on working during the first se
Denies any recent travel outside country in the past 2 weeks
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
Male patient not currently sexually active
Allergies (Food, Drug, Environmental, etc.)
List of Medications/supplements (prescription, OTC, compl
alternative therapies)
Ibuprofen used occasionally for pain.
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Denies any weight gain or loss
HEENT: Denies vision changes. Complaints of sore
throat, cough, right ear pain and headache
Pulmonary: Denies shortness of breath. Reports
From the ROS: list/highlight the current symptoms/comp
list of pertinent “reported or den