Year-Old Female Patient WEEK #7 CASE STUDY
ACTUAL SCREENSHOT PRESENT 60-YEAR-
OLD FEMALE PATIENT REASON SHORTNESS
OF BREATH (6512). WALDEN UNIVERSITY
Compreheni-Human Case Study Evaluation of
Dyspnea with soapnote
,
, WEEK #7 CASE STUDY – ACTUAL SCREENSHOT
STYLE EXAMPLE
Patient: Florence Blackman
Age: 60 years old
Setting: Outpatient Primary Care Clinic with Diagnostic
Lab Access
Reason for Visit: Shortness of Breath
Course: NURS 6512 – Advanced Health Assessment
Institution: Walden University
Week: Week #7 – i-Human Simulation Case
Presenting Complaint (Chief Concern):
, “I’ve been feeling short of breath lately, especially when I walk
or go up stairs. It’s getting worse.”
Initial Data Collected on i-Human Screen:
Category Details
BP: 148/92, HR: 96, RR: 22, Temp: 98.4°F,
Vital Signs
SpO₂: 91% RA
Weight/BMI 178 lbs
Medical
HTN, Hyperlipidemia
History
Medications Lisinopril, Atorvastatin, Multivitamin
Former smoker (20 pack-years), sedentary,
Social History
high-sodium diet
Family History Mother: CHF, Father: Stroke
Physical Exam Findings (on-screen exam tabs):
• HEENT: +JVD
• Lungs: Bibasilar crackles, ↓ breath sounds at bases
• Heart: S3 gallop, regular rhythm, no murmurs
• Extremities: +1 bilateral pitting edema
• General: Appears mildly dyspneic at rest
Lab & Diagnostic Data: