| Complete Clinical Reasoning Guide with Full Patient
Interview, HPI, PMH, Family & Social History, Review of
Systems, Physical Examination, Diagnostic Workup,
Differential Diagnoses.
,SECTION 1: PATIENT DEMOGRAPHICS & INITIAL
ENCOUNTER
Component Details
Patient Name Sheila Davis
Age 62 years old
Gender Female
Race/Ethnicity Caucasian
DOB 03/12/1964
, Component Details
Occupation Retired elementary school teacher
Living Situation Lives alone in a single-story home
Accompanied By Daughter (Jennifer Davis, 35)
Encounter Date 06/28/2026
Setting Outpatient Internal Medicine Clinic
Provider Family Nurse Practitioner
SECTION 2: CHIEF COMPLAINT
"I've been feeling dizzy and unsteady for the past three weeks. It's gotten so bad
that I'm afraid to walk around my house without holding onto the furniture."
SECTION 3: HISTORY OF PRESENTING ILLNESS (HPI)
The "OLDCARTS" Framework
Component Patient's Response
"It started about three weeks ago. I woke up one morning and the room was spinn
Onset
I thought it would go away, but it just keeps happening."
"It feels like the dizziness is in my head—like everything around me is moving.
Location
Sometimes I feel like I'm going to fall over."