IHUMAN CASE STUDY. SHEILA
DAVIS, 68-YEAR-OLD. REASON
FOR ENCOUNTER: DIZZINESS.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Sheila Davis
• Age: 68 years
• Gender: Female
• Marital Status: Married
• Occupation: Retired Teacher
• Source of History: Patient (reliable historian)
Chief Complaint (CC)
"I've been feeling dizzy for about a week."
History of Present Illness (HPI)
Sheila Davis is a 68-year-old female who presents with complaints of
intermittent dizziness that began approximately one week ago. She describes
the dizziness as a spinning sensation that occurs mainly when she changes the
position of her head, such as when rolling over in bed, bending down, looking
upward, or standing up after lying down. Each episode lasts for less than one
minute and usually resolves when she remains still. Over the past several days,
the episodes have become more frequent, causing her to feel unsteady while
walking and making her anxious about falling.
She reports mild nausea during the episodes but denies vomiting. She has not
experienced loss of consciousness, chest pain, palpitations, shortness of
breath, weakness, numbness, facial drooping, slurred speech, blurred vision, or
severe headache. She also denies hearing loss, ringing in the ears, ear pain, ear
discharge, or a feeling of fullness in the ears. There is no history of recent head
injury or upper respiratory tract infection.
The patient has attempted to manage the symptoms by sitting or lying still until
the dizziness subsides. She has also noticed that moving slowly reduces the
DAVIS, 68-YEAR-OLD. REASON
FOR ENCOUNTER: DIZZINESS.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Sheila Davis
• Age: 68 years
• Gender: Female
• Marital Status: Married
• Occupation: Retired Teacher
• Source of History: Patient (reliable historian)
Chief Complaint (CC)
"I've been feeling dizzy for about a week."
History of Present Illness (HPI)
Sheila Davis is a 68-year-old female who presents with complaints of
intermittent dizziness that began approximately one week ago. She describes
the dizziness as a spinning sensation that occurs mainly when she changes the
position of her head, such as when rolling over in bed, bending down, looking
upward, or standing up after lying down. Each episode lasts for less than one
minute and usually resolves when she remains still. Over the past several days,
the episodes have become more frequent, causing her to feel unsteady while
walking and making her anxious about falling.
She reports mild nausea during the episodes but denies vomiting. She has not
experienced loss of consciousness, chest pain, palpitations, shortness of
breath, weakness, numbness, facial drooping, slurred speech, blurred vision, or
severe headache. She also denies hearing loss, ringing in the ears, ear pain, ear
discharge, or a feeling of fullness in the ears. There is no history of recent head
injury or upper respiratory tract infection.
The patient has attempted to manage the symptoms by sitting or lying still until
the dizziness subsides. She has also noticed that moving slowly reduces the
