Case 1 Example 1

A 56-year-old male presents with persistent fatigue and generalized body aches that have been

worsening over the past month. The patient also reports a recent unexplained weight loss of 5 kg

over the last two months. He experiences occasional shortness of breath and has noted a

persistent, dry cough. Additionally, he mentions frequent episodes of night sweats that soak through

his pajamas and sheets.

The symptoms began insidiously about a month ago and have progressively worsened. The body

aches are diffuse, described as a dull and constant ache, predominantly affecting the muscles and

joints. The pain intensity is 5/10 on average but can increase to 7/10 during physical activity or at

the end of the day.

The fatigue and body aches have significantly affected his ability to work as a construction manager,

leading to frequent absences and decreased productivity. He also reports difficulty in completing

daily activities and exercises.

His medical history includes type 2 diabetes mellitus, diagnosed 5 years ago, which is managed with

metformin. He also has a history of hypertension, controlled with lisinopril. His medications are

Metformin 500 mg twice daily, Lisinopril 10 mg daily, and occasional use of ibuprofen for body

aches. He has no known drug allergies.

The patient smokes 10 cigarettes per day and consumes alcohol moderately on weekends. He

denies any recreational drug use. His father had coronary artery disease and passed away at the

age of 60 due to a heart attack. His mother has rheumatoid arthritis.

The patient denies any recent travel or exposure to sick individuals. He has not noticed any
significant changes in his diet or lifestyle that could explain his symptoms. There is no history of

recent infections or trauma. He expresses concern about the possibility of having a serious illness

due to his significant weight loss and persistent symptoms.

Case 1 Example 2

A 60-year-old female presents with chronic lower back pain that radiates to her left leg, worsening

over the past 6 months. She describes the pain as a sharp, shooting pain, with occasional

numbness in her left foot. She reports difficulty standing for long periods and performing her job as a

cashier.

The pain began insidiously and has progressively worsened. She rates the pain at 6/10, increasing

to 8/10 after prolonged standing or physical activity.

Her medical history includes osteoarthritis and type 2 diabetes mellitus, managed with metformin.

She also takes over-the-counter painkillers for her back pain.

She smokes 15 cigarettes per day and has a sedentary lifestyle. Her father had a stroke at age 65,

and her mother has hypertension.

She denies any recent injuries, infections, or significant changes in her lifestyle. She is concerned

about the impact of her pain on her ability to work and her overall quality of life.

Case 1 Example 3

A 45-year-old male presents with persistent chest pain that started suddenly 2 days ago. The pain is

described as a tight, squeezing sensation in the middle of his chest, radiating to his left arm. He also
reports shortness of breath, sweating, and light-headedness.

The pain intensity is 8/10, increasing with physical exertion and relieved by rest.

His medical history includes hypertension and hyperlipidemia, managed with medication. He has a

family history of coronary artery disease, with his father having a heart attack at age 55.

He smokes 20 cigarettes per day and leads a stressful lifestyle due to his job as a financial analyst.

He is concerned about the possibility of having a heart attack and is seeking immediate medical

attention.

Case 1 Example 4

A 50-year-old female presents with severe abdominal pain and bloating that started 1 week ago.

The pain is described as crampy and diffuse, with episodes of sharp pain in the lower abdomen.

She also reports nausea, vomiting, and constipation.

The pain intensity is 7/10, increasing after meals and alleviated slightly by lying down.

Her medical history includes irritable bowel syndrome (IBS) and hypothyroidism, managed with

levothyroxine.

She does not smoke and drinks alcohol occasionally. Her mother had colon cancer, and her father

has diabetes.

She is worried about the possibility of having a serious gastrointestinal condition due to the severity
and persistence of her symptoms.

Case 1 Example 5

A 35-year-old male presents with persistent headaches and visual disturbances that have been

worsening over the past 3 weeks. The headaches are described as a throbbing pain, primarily

located at the back of his head. He also reports double vision and difficulty concentrating at work.

The pain intensity is 6/10, increasing to 8/10 during stressful situations or prolonged screen time.

His medical history is unremarkable, and he is not on any medications.

He does not smoke but drinks alcohol socially. He works as a software developer, which requires

long hours of screen time.

He is concerned about the possibility of having a neurological condition and is seeking a thorough

evaluation.

Case 1 Example 6

A 40-year-old female presents with generalized muscle weakness and fatigue that has been

progressively worsening over the past 2 months. She also reports difficulty swallowing and

occasional shortness of breath.

The weakness is described as a constant feeling of heaviness in her limbs, with a pain intensity of

4/10, increasing to 6/10 during physical activity.

Her medical history includes rheumatoid arthritis, managed with methotrexate and prednisone.

She does not smoke and drinks alcohol occasionally. Her mother had multiple sclerosis, and her

father has hypertension.

She is concerned about the possibility of having a neuromuscular disorder and is seeking a

comprehensive evaluation.

Case 1 Example 7

A 55-year-old male presents with persistent knee pain that started insidiously 3 months ago. The

pain is described as a deep ache, predominantly in the right knee, and is associated with occasional

swelling and stiffness.

The pain intensity is 5/10, increasing to 7/10 after prolonged standing or walking.

His medical history includes gout, managed with allopurinol, and hypertension, managed with

amlodipine.

He smokes 10 cigarettes per day and drinks alcohol moderately. His father had osteoarthritis, and

his mother has rheumatoid arthritis.

He is concerned about the impact of his knee pain on his mobility and overall quality of life.

Case 1 Example 8

A 47-year-old female presents with severe upper abdominal pain and jaundice that started 3 days
ago. The pain is described as a constant, sharp pain in the right upper quadrant, radiating to the

back. She also reports nausea, vomiting, and dark-colored urine.

The pain intensity is 8/10, increasing after meals and alleviated slightly by lying down.

Her medical history includes gallstones and hypercholesterolemia, managed with atorvastatin.

She does not smoke and drinks alcohol occasionally. Her father had liver disease, and her mother

has hypertension.

She is worried about the possibility of having a serious liver condition and is seeking immediate

medical attention.

Case 1 Example 9

A 42-year-old male presents with persistent lower back pain and numbness in his right leg that

started 4 weeks ago. The pain is described as a sharp, shooting pain, with occasional weakness in

his right leg. He reports difficulty sitting for long periods and performing his job as a delivery driver.

The pain intensity is 6/10, increasing to 8/10 after prolonged sitting or physical activity.

His medical history includes a herniated disc, diagnosed 2 years ago, and type 2 diabetes mellitus,

managed with metformin.

He smokes 15 cigarettes per day and has a sedentary lifestyle. His father had a stroke at age 60,

and his mother has hypertension.

He is concerned about the impact of his back pain on his ability to work and his overall quality of life.

Case 1 Example 10

A 58-year-old female presents with persistent cough and shortness of breath that have been

worsening over the past month. The cough is dry and non-productive, and she also reports

wheezing and chest tightness.

The symptoms began insidiously and have progressively worsened. She rates the shortness of

breath at 5/10, increasing to 7/10 during physical activity or at night.

Her medical history includes chronic obstructive pulmonary disease (COPD) and hypertension,

managed with medication.

She smokes 20 cigarettes per day and has a history of recurrent respiratory infections. Her father

had lung cancer, and her mother has asthma.

She is concerned about the possibility of having a serious respiratory condition and is seeking a

thorough evaluation.