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Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.
Demographics: 56-year-old female
Subjective
Chief Complaint (CC): Persistent cold with a dry cough, muscle aches, headache, shivering, and fatigue for several weeks.
History of Present Illness (HPI):
• Duration: Several weeks
• Quality: Dry, jacking cough; muscle aches; headache
• Associated symptoms: Shivering despite hot weather, fatigue
• Aggravating factors: None specified
• Alleviating factors: None effective, over-the-counter medications tried with no effect effect
• additional information: patient states that the symptoms have persisted despite various treatments.
Questions related to CC:
• Have you experienced any shortness of breath or difficulty breathing?
• Have you had any chest pain?
• Do you have any history of respiratory illness or conditions such as asthma or COPD?
• Have you noticed any palpitations or irregular heartbeats?
• Any swelling in your legs or ankles?
• Have you had any dizziness or light-headedness?
• Any change in vision or speech?
• Have you had any recent weight loss or loss of appetite?
• Have you traveled recently or been in contact with anyone who was sick?
