I-HUMAN SHEILA DAVIS CASE STUDY | 68-YEAR-OLD FEMALE
WITH DIZZINESS | COMPLETE CLINICAL REASONING & CASE
ANALYSIS | ASSESSMENT, DIFFERENTIAL DIAGNOSIS &
MANAGEMENT | A+ NURSING STUDY GUIDE | 2026/2027 UPDATE
,TABLE OF CONTENTS
1. Case Overview and Demographics
2. Chief Complaint
3. History of Present Illness (HPI) — OLD CARTS Format
4. Past Medical History
5. Past Surgical History
6. Medications
7. Allergies
8. Family History
9. Social History
10. Review of Systems (ROS)
11. Physical Examination
12. Diagnostic Workup and Laboratory Studies
13. Differential Diagnosis
14. Clinical Reasoning and Analysis
15. Final Diagnosis
16. Treatment and Management Plan
17. Patient Education and Follow-up
18. SOAP Note
19. Clinical Pearls and Key Takeaways
20. Multiple-Choice Review Questions
21. Answer Key with Rationales
22. References
SECTION 1: CASE OVERVIEW AND DEMOGRAPHICS
,Category Details
Patient Name Sheila Davis
Age 68 years
Gender Female
Height 5'2" (157 cm)
Weight 150.0 lb (68.2 kg)
BMI 27.4 kg/m² (overweight)
Marital Status Married
Occupation Retired Teacher
Reason for Encounter Dizziness
Location Outpatient clinic with laboratory capabilities
Source of History Patient (reliable historian)
Date of Encounter 2026
Case Synopsis:
Sheila Davis is a 68-year-old retired teacher who presents to an outpatient clinic with a
one-week history of intermittent dizziness. She describes a spinning sensation (true
vertigo) triggered by head position changes, particularly when rolling over in bed, bending
down, looking upward, or standing up after lying down. Each episode lasts less than one
, minute and resolves with stillness. The episodes have increased in frequency over the past
several days, causing unsteadiness while walking and significant anxiety about falling. She
reports mild nausea during episodes but denies vomiting, loss of consciousness, chest
pain, palpitations, shortness of breath, weakness, numbness, focal neurologic deficits,
hearing loss, tinnitus, or ear-related symptoms. There is no history of recent head injury or
upper respiratory tract infection.
SECTION 2: CHIEF COMPLAINT
Chief Complaint (CC):
"I've been feeling dizzy and lightheaded for the past few days. It feels like the room is
spinning, and I'm afraid I might fall."
SECTION 3: HISTORY OF PRESENT ILLNESS (HPI) — OLD CARTS FORMAT
OLD CARTS
Details
Component
Onset Approximately one week ago
Location Generalized; sensation of room spinning
Duration Each episode lasts < 1 minute; some episodes lasting 5–30 minutes
Character "Room-spinning" vertigo (true rotational vertigo)
Head movement, position changes (rolling over in bed, bending down, looking
Aggravating Factors
upward, standing up after lying down)
Relieving Factors Remaining still; sitting or lying down until dizziness subsides
Timing Episodic; 3–4 episodes per day
WITH DIZZINESS | COMPLETE CLINICAL REASONING & CASE
ANALYSIS | ASSESSMENT, DIFFERENTIAL DIAGNOSIS &
MANAGEMENT | A+ NURSING STUDY GUIDE | 2026/2027 UPDATE
,TABLE OF CONTENTS
1. Case Overview and Demographics
2. Chief Complaint
3. History of Present Illness (HPI) — OLD CARTS Format
4. Past Medical History
5. Past Surgical History
6. Medications
7. Allergies
8. Family History
9. Social History
10. Review of Systems (ROS)
11. Physical Examination
12. Diagnostic Workup and Laboratory Studies
13. Differential Diagnosis
14. Clinical Reasoning and Analysis
15. Final Diagnosis
16. Treatment and Management Plan
17. Patient Education and Follow-up
18. SOAP Note
19. Clinical Pearls and Key Takeaways
20. Multiple-Choice Review Questions
21. Answer Key with Rationales
22. References
SECTION 1: CASE OVERVIEW AND DEMOGRAPHICS
,Category Details
Patient Name Sheila Davis
Age 68 years
Gender Female
Height 5'2" (157 cm)
Weight 150.0 lb (68.2 kg)
BMI 27.4 kg/m² (overweight)
Marital Status Married
Occupation Retired Teacher
Reason for Encounter Dizziness
Location Outpatient clinic with laboratory capabilities
Source of History Patient (reliable historian)
Date of Encounter 2026
Case Synopsis:
Sheila Davis is a 68-year-old retired teacher who presents to an outpatient clinic with a
one-week history of intermittent dizziness. She describes a spinning sensation (true
vertigo) triggered by head position changes, particularly when rolling over in bed, bending
down, looking upward, or standing up after lying down. Each episode lasts less than one
, minute and resolves with stillness. The episodes have increased in frequency over the past
several days, causing unsteadiness while walking and significant anxiety about falling. She
reports mild nausea during episodes but denies vomiting, loss of consciousness, chest
pain, palpitations, shortness of breath, weakness, numbness, focal neurologic deficits,
hearing loss, tinnitus, or ear-related symptoms. There is no history of recent head injury or
upper respiratory tract infection.
SECTION 2: CHIEF COMPLAINT
Chief Complaint (CC):
"I've been feeling dizzy and lightheaded for the past few days. It feels like the room is
spinning, and I'm afraid I might fall."
SECTION 3: HISTORY OF PRESENT ILLNESS (HPI) — OLD CARTS FORMAT
OLD CARTS
Details
Component
Onset Approximately one week ago
Location Generalized; sensation of room spinning
Duration Each episode lasts < 1 minute; some episodes lasting 5–30 minutes
Character "Room-spinning" vertigo (true rotational vertigo)
Head movement, position changes (rolling over in bed, bending down, looking
Aggravating Factors
upward, standing up after lying down)
Relieving Factors Remaining still; sitting or lying down until dizziness subsides
Timing Episodic; 3–4 episodes per day
