COMPREHENSIVE SOAP NOTE
AND CASE ANALYSIS FOR
BRENDA JAMES A 58 FEMALE
• Case Study: Fatigue and Dyspnea in Primary Care
• Patient: Brenda James, 58-year-old Female
• Course: NRNP 6531
Slide 2: Patient Bio-Data & Demographics
• Name: Brenda James
• Age: 58
• Gender: Female
• Race/Ethnicity: African American
• Marital Status: Married
• Occupation: Administrative Assistant (sedentary desk job)
• Code Status: Full Code
Slide 3: History of Present Illness (HPI)
• Brenda presents to the primary care clinic complaining of
progressive fatigue and dyspnea on exertion (DOE) over the past 4
weeks.
, • Onset: Gradual, noticed initially when walking to her car after
work.
• Location: Generalized fatigue; shortness of breath in chest.
• Duration: Constant fatigue; dyspnea occurs with minimal exertion
(climbing 1 flight of stairs).
• Characteristics: "Heaviness" in chest when short of breath, no
sharp pain. Fatigue described as "bone-tired" despite adequate
sleep.
• Aggravating Factors: Physical exertion, lying flat (orthopnea - she
now uses 2 pillows), bending over.
• Relieving Factors: Resting for 5-10 minutes, sitting upright.
• Timing: Worse at the end of the day.
• Severity: Fatigue 7/10; Dyspnea 6/10. Significantly impacts her
ability to do household chores.
Slide 4: Past Medical History (PMH)
• Hypertension (HTN): Diagnosed 10 years ago.
• Type 2 Diabetes Mellitus (T2DM): Diagnosed 5 years ago.
• Hyperlipidemia (HLD): Diagnosed 5 years ago.
• Obesity: BMI 34.
• Surgeries: None.
• Hospitalizations: None.
Slide 5: Medications & Allergies
• Current Medications:
AND CASE ANALYSIS FOR
BRENDA JAMES A 58 FEMALE
• Case Study: Fatigue and Dyspnea in Primary Care
• Patient: Brenda James, 58-year-old Female
• Course: NRNP 6531
Slide 2: Patient Bio-Data & Demographics
• Name: Brenda James
• Age: 58
• Gender: Female
• Race/Ethnicity: African American
• Marital Status: Married
• Occupation: Administrative Assistant (sedentary desk job)
• Code Status: Full Code
Slide 3: History of Present Illness (HPI)
• Brenda presents to the primary care clinic complaining of
progressive fatigue and dyspnea on exertion (DOE) over the past 4
weeks.
, • Onset: Gradual, noticed initially when walking to her car after
work.
• Location: Generalized fatigue; shortness of breath in chest.
• Duration: Constant fatigue; dyspnea occurs with minimal exertion
(climbing 1 flight of stairs).
• Characteristics: "Heaviness" in chest when short of breath, no
sharp pain. Fatigue described as "bone-tired" despite adequate
sleep.
• Aggravating Factors: Physical exertion, lying flat (orthopnea - she
now uses 2 pillows), bending over.
• Relieving Factors: Resting for 5-10 minutes, sitting upright.
• Timing: Worse at the end of the day.
• Severity: Fatigue 7/10; Dyspnea 6/10. Significantly impacts her
ability to do household chores.
Slide 4: Past Medical History (PMH)
• Hypertension (HTN): Diagnosed 10 years ago.
• Type 2 Diabetes Mellitus (T2DM): Diagnosed 5 years ago.
• Hyperlipidemia (HLD): Diagnosed 5 years ago.
• Obesity: BMI 34.
• Surgeries: None.
• Hospitalizations: None.
Slide 5: Medications & Allergies
• Current Medications:
