IHuman Case Study: 28-Year-Old Male With Persistent Cough And Fatigue

iHuman Case Study: Cough and Fatigue in a 28-Year-Old Male

Patient Profile

• Name: Mr. John M. (alias for privacy)

• Age: 28 years

• Sex: Male

• Occupation: Software engineer

• Marital Status: Single

• Residence: Urban apartment in a metropolitan area

• Date of Presentation: October 1, 2025

Chief Complaints

• Persistent dry cough for 3 weeks

• Fatigue and low energy levels for approximately 1 month

History of Present Illness

Mr. John M. is a previously healthy 28-year-old male who presented to the outpatient clinic with complaints of a non-productive dry cough that began insidiously around 3 weeks ago. The cough is worse at night and during physical exertion. He denies any sputum production, hemoptysis, or wheezing.

He also reports a progressive feeling of fatigue over the past month, which he initially attributed to work-related stress. He now finds it difficult to exercise or complete daily tasks due to tiredness. No history of fever, weight loss, or night sweats is reported. He denies chest pain, shortness of breath, or palpitations.

Past Medical History

• No known chronic illnesses

• No history of asthma, TB, or recent infections

• No recent hospitalizations or surgeries

Medications

• Occasionally takes over-the-counter paracetamol for headaches

• No known drug allergies

Social History

• Non-smoker

• Occasional alcohol use

• Denies recreational drug use

• Lives alone

• No recent travel or known sick contacts

• Works remotely; sedentary lifestyle

• No pets

Family History

• Mother with hypothyroidism

• Father has type 2 diabetes

• No family history of asthma, TB, or autoimmune disease

Review of Systems

• No fever, chills, or night sweats

• No recent weight changes

• No gastrointestinal or genitourinary symptoms

• No rashes or joint pain

Physical Examination