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68-year-old, Maura Smith IHuman Comprehensive Case Study

HEAL100 Health Care — exam and revision material · Other

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Health Care case study material, 13 pages. Originally published on StudyMerit.

Pages
13
Academic year
2025/2026
Language
English

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-_— A OTe IN Ou #00007 | ASKAINT DAAC TAT THAIN PA wot Nn rage 10 let Wa won 0d Te Reg | eB saat @ iy rn i LONE set BY Maura Smith Yor srt 4 pnt + Nant JO wh et wn USA, re Pe comp f 4 od wd DOC tr | Mc [iam : oA ge 8 re ee Sed | Ae + sre, Wi od mile OW Mr Ya a vi toe AP J WL IC ee a Es sing, Pee ee cur ae Py Bae pret EDC Pues ey Rear tw cate ee 2 Sr? (od wt Bert Po we atvwut ty oo pve

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| Section Title (x | Patient Demographics & Identifying Data 2 Chief Complaint (CC) 3 History of Present Iliness (HPI) — The OLD CARTS Method El 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 8 IDENTIFYING DATA « Patient Name: Maura Smith « Age: 68 years old « Sex: Female « Reason for Encounter: Dizziness

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« Primary Concern: Maura presents for evaluation of dizziness that has been concerning enough to seek medical attention. « At 68 years of age, dizziness requires careful assessment because it may result from a relatively benign condition, such as a positional vestibular disorder, but may also be associated with cardiovascular, neurologic, medication-related, metabolic, or other medical conditions. « The initial assessment should clarify exactly what Maura means by “dizziness,” since patients may use this term to describe: = Aspinning sensation. = Feeling lightheaded or faint. = Loss of balance or unsteadiness. = Avague sensation of being off-balance. « Her medication history, cardiovascular risk factors, neurologic symptoms, recent lliness, hydration status, and history of falls should be reviewed carefully, « The history should also establish whether the dizziness is new, recurrent, sudden, or gradually developing and whether it interferes with walking or normal daily activities. 2. CHIEF COMPLAINT (CC) « Chief Complaint: “I've been feeling dizzy” « Maura Smith is a 68-year-old woman presenting because of dizziness o The camplaint should be clarfied in her own words to determine the exact sensation she is experiencing o Important clantication includes whether she feels That the room i spinning Lightheaded or as though she might fant

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