Maura Smith 68-year-old, I-human
Case Study, Reasons 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 and Demographic Information
• Name: Maura Smith
• Age: 68 years
• Sex: Female
• Reason for encounter: Dizziness
• Source of history: Patient
• Reliability of historian: Patient appears able to provide a consistent history
• Encounter type: Evaluation of dizziness
Chief Complaint
• “Dizziness.”
, • The patient presents for evaluation of dizziness that has been affecting her usual
activities.
History of Present Illness
Maura Smith is a 68-year-old female who presents with a complaint of dizziness. She reports
experiencing episodes in which she feels dizzy or unsteady. The sensation has prompted her
to seek medical evaluation because of concern about its cause and the possibility of falling
or losing her balance.
The dizziness should be characterized further according to the patient's description. It is
important to determine whether she feels that the room or surroundings are spinning,
whether she feels light-headed as though she may faint, or whether she mainly feels
unsteady while standing or walking. Clarifying the exact sensation helps distinguish between
vertigo, presyncope, and disequilibrium.
The timing and pattern of the episodes should also be established. Information regarding
when the dizziness began, how frequently it occurs, how long each episode lasts, and
whether it is becoming more frequent or severe is relevant. The relationship between the
dizziness and changes in position, such as standing from a sitting or lying position, should be
assessed. Any association with walking, turning the head, bending over, or getting out of bed
should also be documented.
Associated symptoms should be assessed carefully. These include headache, nausea,
vomiting, blurred or double vision, weakness, numbness, difficulty speaking, hearing
changes, ringing in the ears, chest discomfort, palpitations, shortness of breath, loss of
consciousness, or difficulty walking. These symptoms can help identify whether the dizziness
may be related to a vestibular, cardiovascular, neurologic, metabolic, or other cause.
The patient's fluid and food intake should also be reviewed. Reduced fluid intake, poor
nutrition, vomiting, diarrhea, or excessive sweating may contribute to dizziness through
dehydration or changes in blood pressure. Medication use should be reviewed because
several medications commonly used by older adults can contribute to dizziness, low blood
pressure, sedation, or balance problems.
The patient should also be asked whether she has experienced any recent falls, near-falls, or
injuries. Because she is 68 years old, dizziness may increase her risk of falling and sustaining
significant injury.
No specific precipitating cause, duration of symptoms, associated symptoms, medication list,
or previous diagnostic results were supplied in the case information. These details therefore
require further assessment rather than being assumed.
Current Symptoms and Associated Concerns
Case Study, Reasons 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 and Demographic Information
• Name: Maura Smith
• Age: 68 years
• Sex: Female
• Reason for encounter: Dizziness
• Source of history: Patient
• Reliability of historian: Patient appears able to provide a consistent history
• Encounter type: Evaluation of dizziness
Chief Complaint
• “Dizziness.”
, • The patient presents for evaluation of dizziness that has been affecting her usual
activities.
History of Present Illness
Maura Smith is a 68-year-old female who presents with a complaint of dizziness. She reports
experiencing episodes in which she feels dizzy or unsteady. The sensation has prompted her
to seek medical evaluation because of concern about its cause and the possibility of falling
or losing her balance.
The dizziness should be characterized further according to the patient's description. It is
important to determine whether she feels that the room or surroundings are spinning,
whether she feels light-headed as though she may faint, or whether she mainly feels
unsteady while standing or walking. Clarifying the exact sensation helps distinguish between
vertigo, presyncope, and disequilibrium.
The timing and pattern of the episodes should also be established. Information regarding
when the dizziness began, how frequently it occurs, how long each episode lasts, and
whether it is becoming more frequent or severe is relevant. The relationship between the
dizziness and changes in position, such as standing from a sitting or lying position, should be
assessed. Any association with walking, turning the head, bending over, or getting out of bed
should also be documented.
Associated symptoms should be assessed carefully. These include headache, nausea,
vomiting, blurred or double vision, weakness, numbness, difficulty speaking, hearing
changes, ringing in the ears, chest discomfort, palpitations, shortness of breath, loss of
consciousness, or difficulty walking. These symptoms can help identify whether the dizziness
may be related to a vestibular, cardiovascular, neurologic, metabolic, or other cause.
The patient's fluid and food intake should also be reviewed. Reduced fluid intake, poor
nutrition, vomiting, diarrhea, or excessive sweating may contribute to dizziness through
dehydration or changes in blood pressure. Medication use should be reviewed because
several medications commonly used by older adults can contribute to dizziness, low blood
pressure, sedation, or balance problems.
The patient should also be asked whether she has experienced any recent falls, near-falls, or
injuries. Because she is 68 years old, dizziness may increase her risk of falling and sustaining
significant injury.
No specific precipitating cause, duration of symptoms, associated symptoms, medication list,
or previous diagnostic results were supplied in the case information. These details therefore
require further assessment rather than being assumed.
Current Symptoms and Associated Concerns
