WEEK #7 60-YEAR-OLD FEMALE REASON FOR ENCOUNTER:
SHORTNESS OF BREATH I HUMAN CASE STUDY LATEST UPDATE
2024/2025[soap note]
🩺 GENERAL HEALTH
1. Q: How have you been feeling lately?
A: I've been feeling okay, just a bit more tired than usual.
2. Q: Have you had any new symptoms since your last visit?
A: I've had occasional headaches and some dizziness.
3. Q: Are you experiencing any pain currently?
A: Yes, some lower back pain, especially in the mornings.
4. Q: Have you had any recent falls or injuries?
A: I slipped in the kitchen last week but didn’t get seriously hurt.
5. Q: Any changes in your weight?
A: I’ve gained about 3 kg over the last two months.
6. Q: Do you check your blood pressure at home?
A: Yes, it's usually around 140/85.
7. Q: Do you have trouble sleeping?
A: Yes, I wake up several times during the night.
8. Q: Do you feel rested when you wake up?
A: Not really, I still feel tired in the mornings.
9. Q: Any issues with your vision or hearing?
A: My eyesight has worsened a bit, especially at night.
, 10. Q: When was your last eye exam?
A: About a year ago.
❤️ CARDIOVASCULAR & RESPIRATORY
11. Q: Do you ever feel chest pain or tightness?
A: Occasionally when I climb stairs.
12. Q: Do you get short of breath easily?
A: Yes, more than I used to.
13. Q: Do you have a cough?
A: A dry cough that comes and goes.
14. Q: Any swelling in your feet or ankles?
A: Yes, especially in the evenings.
15. Q: Do you have a history of high blood pressure?
A: Yes, I've had it for about 10 years.
16. Q: Are you currently taking any heart medications?
A: Yes, I'm on amlodipine.
17. Q: Have you had an ECG recently?
A: Not in the past year.
18. Q: Do you experience palpitations or irregular heartbeats?
A: Occasionally, especially when I'm anxious.
19. Q: Have you ever been diagnosed with asthma or COPD?
A: No, but I sometimes wheeze when it's cold.
20. Q: Do you snore at night or stop breathing during sleep?
A: I do snore, but I’m not sure if I stop breathing.
SHORTNESS OF BREATH I HUMAN CASE STUDY LATEST UPDATE
2024/2025[soap note]
🩺 GENERAL HEALTH
1. Q: How have you been feeling lately?
A: I've been feeling okay, just a bit more tired than usual.
2. Q: Have you had any new symptoms since your last visit?
A: I've had occasional headaches and some dizziness.
3. Q: Are you experiencing any pain currently?
A: Yes, some lower back pain, especially in the mornings.
4. Q: Have you had any recent falls or injuries?
A: I slipped in the kitchen last week but didn’t get seriously hurt.
5. Q: Any changes in your weight?
A: I’ve gained about 3 kg over the last two months.
6. Q: Do you check your blood pressure at home?
A: Yes, it's usually around 140/85.
7. Q: Do you have trouble sleeping?
A: Yes, I wake up several times during the night.
8. Q: Do you feel rested when you wake up?
A: Not really, I still feel tired in the mornings.
9. Q: Any issues with your vision or hearing?
A: My eyesight has worsened a bit, especially at night.
, 10. Q: When was your last eye exam?
A: About a year ago.
❤️ CARDIOVASCULAR & RESPIRATORY
11. Q: Do you ever feel chest pain or tightness?
A: Occasionally when I climb stairs.
12. Q: Do you get short of breath easily?
A: Yes, more than I used to.
13. Q: Do you have a cough?
A: A dry cough that comes and goes.
14. Q: Any swelling in your feet or ankles?
A: Yes, especially in the evenings.
15. Q: Do you have a history of high blood pressure?
A: Yes, I've had it for about 10 years.
16. Q: Are you currently taking any heart medications?
A: Yes, I'm on amlodipine.
17. Q: Have you had an ECG recently?
A: Not in the past year.
18. Q: Do you experience palpitations or irregular heartbeats?
A: Occasionally, especially when I'm anxious.
19. Q: Have you ever been diagnosed with asthma or COPD?
A: No, but I sometimes wheeze when it's cold.
20. Q: Do you snore at night or stop breathing during sleep?
A: I do snore, but I’m not sure if I stop breathing.
