PRESENTING WITH SHORTNESS OF BREATH AT
OUTPATIENT CLINIC WITH LABORATORY AND IMAGING
CAPABILITIES
,PATIENT INFORMATION
Name: Not provided
Age: 60 years
Sex: Female
Height: 5′4″ (163 cm)
Weight: 183.0 lb (83.0 kg)
Location: Outpatient clinic with laboratory and imaging services
Reason for Encounter: Shortness of breath
The patient is a 60-year-old female presenting with progressively worsening shortness of
breath that has developed insidiously over the past several weeks, affecting her ability to
perform physical tasks and daily activities.
, REASON FOR ENCOUNTER
The patient presents due to progressive dyspnea that has worsened with activity and now
occurs with minimal exertion. The purpose of this visit is to comprehensively evaluate the
cardiopulmonary system, identify contributing factors (including chronic comorbid
conditions), differentiate between cardiac and pulmonary causes, and formulate an evidence-
based diagnostic and treatment plan.
Component Description
Encounter type Outpatient clinic visit
Chief complaint Shortness of breath
Onset Gradual, weeks
Duration Progressive
Location Respiratory/cardiac system
Characteristics Dyspnea on exertion progressing to rest
Aggravating factors Walking, climbing stairs, exertion
Relieving factors Rest, sitting upright
Associated symptoms Mild ankle swelling, dry cough, fatigue
Systemic concerns No fever or chills
Patient goals Improve breathing, determine cause