YEAR OLD MALE PRESENTING WITH FATIGUE AND
SHORTNESS OF BREATH AT OUTPATIENT CLINIC WITH
DIAGNOSTIC AND IMAGING SERVICES
,PATIENT INFORMATION
Name: Asher Wilson
Age: 74 years
Sex: Male
Height: 5′8″ (173 cm)
Weight: 164.0 lb (74.5 kg)
Location: Outpatient clinic with laboratory and imaging services
Reason for Encounter: Fatigue and shortness of breath
Asher Wilson is a 74-year-old male presenting to an outpatient clinic due to
progressively worsening fatigue and shortness of breath that has begun to
interfere with his functional capacity and daily activities.
, REASON FOR ENCOUNTER
The patient presents for evaluation of persistent fatigue and progressive
shortness of breath that has worsened over several months. The goal of this
visit is to identify the underlying cause, assess cardiopulmonary status, and
initiate appropriate management.
Component Description
Encounter type Outpatient visit
Primary concern Fatigue and shortness of breath
Onset Gradual, 2–3 months
Course Progressive
Severity Moderate to severe
Aggravating factors Physical exertion, lying flat
Relieving factors Rest, upright positioning
Associated symptoms Orthopnea, lower extremity edema, dry cough
Functional impact Reduced exercise tolerance
Patient objective Symptom relief and diagnosis