OLD FEMALE PRESENTING WITH FATIGUE AND ARM
WEAKNESS AT OUTPATIENT CLINIC WITH LABORATORY
AND IMAGING CAPABILITIES
,PATIENT INFORMATION
Name: Nina Adams
Age: 45 years
Sex: Female
Height: 5′6″ (167 cm)
Weight: 135.0 lb (61.2 kg)
Location: Outpatient clinic with laboratory and imaging capabilities
Reason for Encounter: Fatigue and arm weakness
Nina Adams is a 45-year-old female presenting with progressive fatigue and weakness in both arms
that has been increasing over several weeks and is now affecting her ability to perform work-related
and daily tasks.
, REASON FOR ENCOUNTER
The patient presents with gradual onset of fatigue and proximal arm weakness limiting activities of
daily living. The evaluation focuses on identifying systemic, endocrine, or neuromuscular causes and
guiding appropriate management.
Component Description
Encounter type Outpatient clinic visit
Chief complaint Fatigue and arm weakness
Onset Gradual, over several weeks
Duration Persistent, progressive
Location Upper extremities (initially right, now bilateral)
Characteristics Weakness described as heaviness and tiring with activity
Aggravating factors Repetitive arm use, work tasks
Relieving factors Rest (minimal improvement)
Associated symptoms Mild exertional shortness of breath, hair thinning, cold intolerance
Systemic concerns No fever, chills, or night sweats
Patient goals Identify cause, restore strength, improve function