PRESENTING WITH DIFFICULTY BREATHING, COUGH, AND
LOW-GRADE FEVER AT OUTPATIENT URGENT CARE CLINIC
UTILIZING SYSTEMATIC HISTORY-DRIVEN ASSESSMENT,
COMPREHENSIVE PHYSICAL EXAMINATION, DIFFERENTIAL
DIAGNOSIS, AND EVIDENCE-BASED MANAGEMENT
,PATIENT INFORMATION
Age: 45 years
Sex: Female
Height: 5′6″ (168 cm)
Weight: 162 lb (73.5 kg)
Location: Outpatient urgent care clinic
Reason for Encounter: Difficulty breathing and cough
Explanation: The patient is a 45-year-old female presenting with progressive shortness of breath
and cough associated with generalized malaise and low-grade fever, requiring a head-to-toe
clinical assessment.
, REASON FOR ENCOUNTER
Category Details
Encounter Type Outpatient urgent care visit
Chief Complaint Shortness of breath and cough
Duration 5 days
Frequency Persistent daily
Associated Symptoms Low-grade fever, fatigue
Aggravating Factors Physical exertion
Relieving Factors Rest
Systemic Symptoms Malaise, chills
Patient Goals Accurate diagnosis and symptom relief
Explanation: The patient presents for evaluation of respiratory symptoms that have
progressively limited her activity and quality of life.