Comprehensive Sheila Davis i-Human Case Study: Dizziness |
Complete Clinical Documentation Featuring Patient History,
HPI, ROS, Physical Examination, Diagnostic Evaluation,
Differential Diagnoses, Final Diagnosis, Comprehensive
SOAP Note
,SECTION 1: PATIENT DEMOGRAPHICS & INITIAL
ENCOUNTER
Component Details
Patient Name Sheila Davis
Age 62 years old
,Component Details
Gender Female
Race/Ethnicity Caucasian
DOB 03/12/1964
Occupation Retired elementary school teacher
Living Situation Lives alone in a single-story home
Accompanied By Daughter (Jennifer Davis, age 35)
Encounter Date 06/28/2026
Setting Outpatient Internal Medicine Clinic
Provider Family Nurse Practitioner
SECTION 2: CHIEF COMPLAINT
"I've been feeling dizzy and unsteady for the past three weeks. It's gotten so bad that I'm
afraid to walk around my house without holding onto the furniture."
SECTION 3: HISTORY OF PRESENTING ILLNESS (HPI)
Critical First Question
, Question Patient's Response
"What do you mean by "It's a spinning sensation—like the room is tilting or rotating around me. Other
dizzy?" times, it just feels like I'm walking on a boat."
Clinical Pearl: This distinction is critical—the patient is describing vertigo (spinning
sensation) rather than lightheadedness or presyncope. This immediately directs the
differential toward vestibular/neurological causes. Dizziness is often caused by conditions
that affect the balance organ in the inner ear.
The "OLDCARTS" Framework
Component Patient's Response
"It started about three weeks ago. I woke up one morning and the room was spinnin
Onset
thought it would go away, but it just keeps happening."
"It feels like the dizziness is in my head—like everything around me is moving.
Location
Sometimes I feel like I'm going to fall over."
"The episodes last anywhere from a few minutes to several hours. On bad days, I fee
Duration
unsteady all day long."
"It's a spinning sensation—like the room is tilting or rotating around me. Other time
Character/Quality
just feels like I'm walking on a boat. I also get a feeling of fullness in my right ear."
Aggravating "It gets worse when I turn my head quickly, roll over in bed, or look up. It also seems
Factors worse when I'm tired or stressed."
"If I lie still and don't move my head, it slowly gets better. I also feel a little better if I
Relieving Factors
in a dark, quiet room."
"It's worse in the morning when I first wake up and when I move my head. Sometim
Timing
it's triggered by sudden movements."
"On a scale of 0 to 10, it's usually a 6 or 7 when it's bad. Sometimes I have to hold o
Severity
the wall just to walk to the bathroom."
Complete Clinical Documentation Featuring Patient History,
HPI, ROS, Physical Examination, Diagnostic Evaluation,
Differential Diagnoses, Final Diagnosis, Comprehensive
SOAP Note
,SECTION 1: PATIENT DEMOGRAPHICS & INITIAL
ENCOUNTER
Component Details
Patient Name Sheila Davis
Age 62 years old
,Component Details
Gender Female
Race/Ethnicity Caucasian
DOB 03/12/1964
Occupation Retired elementary school teacher
Living Situation Lives alone in a single-story home
Accompanied By Daughter (Jennifer Davis, age 35)
Encounter Date 06/28/2026
Setting Outpatient Internal Medicine Clinic
Provider Family Nurse Practitioner
SECTION 2: CHIEF COMPLAINT
"I've been feeling dizzy and unsteady for the past three weeks. It's gotten so bad that I'm
afraid to walk around my house without holding onto the furniture."
SECTION 3: HISTORY OF PRESENTING ILLNESS (HPI)
Critical First Question
, Question Patient's Response
"What do you mean by "It's a spinning sensation—like the room is tilting or rotating around me. Other
dizzy?" times, it just feels like I'm walking on a boat."
Clinical Pearl: This distinction is critical—the patient is describing vertigo (spinning
sensation) rather than lightheadedness or presyncope. This immediately directs the
differential toward vestibular/neurological causes. Dizziness is often caused by conditions
that affect the balance organ in the inner ear.
The "OLDCARTS" Framework
Component Patient's Response
"It started about three weeks ago. I woke up one morning and the room was spinnin
Onset
thought it would go away, but it just keeps happening."
"It feels like the dizziness is in my head—like everything around me is moving.
Location
Sometimes I feel like I'm going to fall over."
"The episodes last anywhere from a few minutes to several hours. On bad days, I fee
Duration
unsteady all day long."
"It's a spinning sensation—like the room is tilting or rotating around me. Other time
Character/Quality
just feels like I'm walking on a boat. I also get a feeling of fullness in my right ear."
Aggravating "It gets worse when I turn my head quickly, roll over in bed, or look up. It also seems
Factors worse when I'm tired or stressed."
"If I lie still and don't move my head, it slowly gets better. I also feel a little better if I
Relieving Factors
in a dark, quiet room."
"It's worse in the morning when I first wake up and when I move my head. Sometim
Timing
it's triggered by sudden movements."
"On a scale of 0 to 10, it's usually a 6 or 7 when it's bad. Sometimes I have to hold o
Severity
the wall just to walk to the bathroom."
