NR324 iHuman Randall Davis — Full Case, SOAP Note &
PowerPoint
PART ONE: FULL CASE STUDY — RANDALL DAVIS
Patient Profile
Name: Randall Davis
Age: 58 years old
Sex: Male
Height: 5'10" (178 cm)
Weight: 215 lb (97.5 kg)
BMI: 30.9 (Obesity Class I)
Code Status: Full Code
Allergies: Penicillin (rash)
Chief Complaint: "I've been getting short of breath and my legs are swelling."
History of Present Illness
Randall Davis is a 58-year-old male who presents to the emergency department with a 5-day
history of progressively worsening dyspnea on exertion, orthopnea (requiring 3 pillows to
sleep), and bilateral lower extremity edema. He reports a 12-pound weight gain over the past
week. He describes episodes of paroxysmal nocturnal dyspnea, waking him from sleep gasping
for air. He has noticed increased fatigue and decreased exercise tolerance, now unable to walk
to his mailbox without stopping to catch his breath. He denies chest pain but reports a
persistent, nonproductive cough that is worse when lying flat. He has not taken his medications
consistently over the past two weeks because he "ran out and didn't refill them."
Past Medical History
Hypertension (diagnosed 12 years ago)
Type 2 diabetes mellitus (diagnosed 8 years ago)
Heart failure with reduced ejection fraction (HFrEF), ejection fraction 35% on last
echocardiogram
Hyperlipidemia
Chronic kidney disease Stage 2
Past Surgical History
, Appendectomy (age 22)
Coronary artery stent placement (age 55)
Current Medications
Lisinopril 20 mg PO daily
Carvedilol 12.5 mg PO BID
Metformin 1000 mg PO BID
Atorvastatin 40 mg PO nightly
Furosemide 40 mg PO daily
Potassium chloride 20 mEq PO daily
Social History
Married, lives with wife
Former smoker: 1 pack per day for 25 years, quit 5 years ago
Alcohol: 2-3 beers on weekends
Occupation: Retired truck driver
Family History
Father: Myocardial infarction at age 62, deceased at 70
Mother: Hypertension, Type 2 diabetes, alive at 82
Brother: Heart failure, alive at 55
Review of Systems
General: Reports fatigue, 12-lb weight gain, decreased appetite. Denies fever or chills.
HEENT: Denies headache, vision changes, sore throat, or difficulty swallowing.
Cardiovascular: Reports palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal
dyspnea, and bilateral lower extremity edema. Denies chest pain, syncope, or claudication.
Respiratory: Reports nonproductive cough worse when supine, shortness of breath. Denies
hemoptysis, wheezing, or pleuritic chest pain.
Gastrointestinal: Reports mild abdominal bloating. Denies nausea, vomiting, diarrhea, or
constipation.
Genitourinary: Reports nocturia (3-4 times per night). Denies dysuria or hematuria.
PowerPoint
PART ONE: FULL CASE STUDY — RANDALL DAVIS
Patient Profile
Name: Randall Davis
Age: 58 years old
Sex: Male
Height: 5'10" (178 cm)
Weight: 215 lb (97.5 kg)
BMI: 30.9 (Obesity Class I)
Code Status: Full Code
Allergies: Penicillin (rash)
Chief Complaint: "I've been getting short of breath and my legs are swelling."
History of Present Illness
Randall Davis is a 58-year-old male who presents to the emergency department with a 5-day
history of progressively worsening dyspnea on exertion, orthopnea (requiring 3 pillows to
sleep), and bilateral lower extremity edema. He reports a 12-pound weight gain over the past
week. He describes episodes of paroxysmal nocturnal dyspnea, waking him from sleep gasping
for air. He has noticed increased fatigue and decreased exercise tolerance, now unable to walk
to his mailbox without stopping to catch his breath. He denies chest pain but reports a
persistent, nonproductive cough that is worse when lying flat. He has not taken his medications
consistently over the past two weeks because he "ran out and didn't refill them."
Past Medical History
Hypertension (diagnosed 12 years ago)
Type 2 diabetes mellitus (diagnosed 8 years ago)
Heart failure with reduced ejection fraction (HFrEF), ejection fraction 35% on last
echocardiogram
Hyperlipidemia
Chronic kidney disease Stage 2
Past Surgical History
, Appendectomy (age 22)
Coronary artery stent placement (age 55)
Current Medications
Lisinopril 20 mg PO daily
Carvedilol 12.5 mg PO BID
Metformin 1000 mg PO BID
Atorvastatin 40 mg PO nightly
Furosemide 40 mg PO daily
Potassium chloride 20 mEq PO daily
Social History
Married, lives with wife
Former smoker: 1 pack per day for 25 years, quit 5 years ago
Alcohol: 2-3 beers on weekends
Occupation: Retired truck driver
Family History
Father: Myocardial infarction at age 62, deceased at 70
Mother: Hypertension, Type 2 diabetes, alive at 82
Brother: Heart failure, alive at 55
Review of Systems
General: Reports fatigue, 12-lb weight gain, decreased appetite. Denies fever or chills.
HEENT: Denies headache, vision changes, sore throat, or difficulty swallowing.
Cardiovascular: Reports palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal
dyspnea, and bilateral lower extremity edema. Denies chest pain, syncope, or claudication.
Respiratory: Reports nonproductive cough worse when supine, shortness of breath. Denies
hemoptysis, wheezing, or pleuritic chest pain.
Gastrointestinal: Reports mild abdominal bloating. Denies nausea, vomiting, diarrhea, or
constipation.
Genitourinary: Reports nocturia (3-4 times per night). Denies dysuria or hematuria.
