YEAR OLD FEMALE PRESENTING WITH SHORTNESS OF
BREATH AT OUTPATIENT CLINIC WITH LABORATORY
AND IMAGING CAPABILITIES
,PATIENT INFORMATION
Name: Jamie Feldman
Age: 67 years
Sex: Female
Height: 5′6″ (168 cm)
Weight: 174.0 lb (79.1 kg)
Location: Outpatient clinic with laboratory and imaging capabilities
Reason for Encounter: Shortness of breath
Jamie Feldman is a 67-year-old female presenting with shortness of breath that has been persistent
and progressively affecting her functional capacity, especially on exertion. She seeks evaluation to
identify underlying causes, assess cardiac and pulmonary function, and develop an appropriate
management plan.
, REASON FOR ENCOUNTER
Jamie presents with a chief complaint of shortness of breath of approximately one month’s
duration, worsened with activity and impacting daily functioning. The evaluation focuses on
determining cardiac versus pulmonary etiologies, associated symptoms, and related risk factors.
Component Description
Encounter type Outpatient clinic visit
Chief complaint Shortness of breath
Onset ~1 month ago
Duration Persistent, worsens with activity
Location Respiratory
Characteristics Progressive dyspnea with exertion
Aggravating factors Walking, stairs
Relieving factors Rest
Associated symptoms Intermittent mild chest discomfort
Systemic concerns No fever reported
Patient goals Determine cause, improve breathing and tolerance to activity