Week 3 NR602 iHuman cough and shortness of breath

Laia Nunez
16 y/o
5′ 5″ (165 cm)
150.0 lb (68.2 kg)

Reason for encounter
Cough and shortness of breath

Location
Outpatient clinic with x-ray, ECG, and laboratory capabilities

Sample of the case content-Full version  include ALL history, physical  exam, findings, test, diagnosis, and plan

HISTORY Questions:
Skin: pink, warm, moist
1. How can I help you today?
Cough for the last three weeks which has been getting worse. I’ve also had SOB when
walking to my next class at school. I have to stop and take a break.
2. Do you have any other symptoms or concerns we should discuss?
No, but I did have a runny nose and congestion 3 weeks ago. The congestion went away
in a week but the cough is still there.
HPI: Cough:
3. Are you coughing up any sputum?
No
4. Does anything make your cough better or worse?
Not really, it has been constant but has been getting worse over the past three days and
seems to be worse at nights.
5. What treatments have you had for your cough?
Nothing
PMH:
6. Do you have any allergies?
No
7. Are you taking any prescription medications?

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