A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks.
She has been complaining of dry cough since the past two weeks and low grade fever
that started two days ago, and was as high as 101 orally. She has had a decreased
appetite but no nausea and vomiting. The cough occurs during the night and she needs
to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely
She had been prescribed inhalers in the past; they have been helpful but she does not
use them on a routine basis. She has been prescribed antibiotics in the past as well and
that seems to help when she is acutely ill. She has been suffering from shortness of
breath for the past two weeks following any kind of activity mainly because of the dry
cough. She thinks itâ€™s possible that thereâ€™s some problem with her â€œheart.â€ She is also
complaining of slight sore throat, especially in the morning and feels she may have lung
The patientâ€™s symptoms have been worsening over the past two days.
She has had similar episodes in the past. The last was three months ago when she had
to go to the emergency room and they told her that she needed to be hospitalized. She
declined hospitalization at that time and was treated and released. She says they gave
her antibiotics and an inhaler before discharging her. She mentioned that though it took
some time to feel better, there was gradual improvement in her condition following that
treatment. According to her, this is the worst episode that she can remember. Sheâ€™s very
concerned today that she could have pneumonia and might require hospitalization.
She is seeking medical attention today because of the fever and prolonged nature of her
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