IHUMAN COMPREHENSIVE CASE
STUDY SHEILA DAVIS, 68-YEAR-
OLD. REASON FOR ENCOUNTER:
DIZZINESS.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents.
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
, 1. Patient Demographics & Identifying Data
Name: Sheila Davis
Age: 68 years old
Gender: Female
Date of Visit: __________________
Source of History: Patient (reliable historian)
Accompanied By: Husband
Race/Ethnicity: Not specified
Marital Status: Married
Occupation: Retired Elementary School Teacher
Primary Language: English
Chief Concern: Recurrent episodes of dizziness that have become more
frequent over the past several days.
Reason for Encounter: Dizziness.
Mode of Arrival: Arrived at the clinic with her husband for evaluation of
persistent dizziness.
Level of Consciousness: Alert, awake, and fully oriented to person, place, time,
and situation.
General Appearance: Pleasant elderly female who appears her stated age.
Well-groomed and appropriately dressed. Appears mildly anxious and cautious
with movement because of dizziness but is in no acute distress. She ambulates
slowly and carefully while holding onto her husband's arm for stability.
STUDY SHEILA DAVIS, 68-YEAR-
OLD. REASON FOR ENCOUNTER:
DIZZINESS.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents.
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
, 1. Patient Demographics & Identifying Data
Name: Sheila Davis
Age: 68 years old
Gender: Female
Date of Visit: __________________
Source of History: Patient (reliable historian)
Accompanied By: Husband
Race/Ethnicity: Not specified
Marital Status: Married
Occupation: Retired Elementary School Teacher
Primary Language: English
Chief Concern: Recurrent episodes of dizziness that have become more
frequent over the past several days.
Reason for Encounter: Dizziness.
Mode of Arrival: Arrived at the clinic with her husband for evaluation of
persistent dizziness.
Level of Consciousness: Alert, awake, and fully oriented to person, place, time,
and situation.
General Appearance: Pleasant elderly female who appears her stated age.
Well-groomed and appropriately dressed. Appears mildly anxious and cautious
with movement because of dizziness but is in no acute distress. She ambulates
slowly and carefully while holding onto her husband's arm for stability.
