2025/2026 i-Human Regina Ricardo
Case Study: 65-Year-Old Female with
Trouble Sleeping | Advanced Health
Assessment Week 3 Comprehensive
SOAP Note by i-Human Clinical
Specialists | Pass Your Exam First
Attempt
,Based on the comprehensive 2025/2026 i-Human case study for **Bertie Bridges**, an 86-year-old
female presenting with progressive fatigue and an alarming episode of dyspnea with palpitations, here is
the optimized, complete SOAP note and management guide designed to help you pass on your first
attempt.
---
## 📋 Case Overview
| Category | Details |
| :--- | :--- |
| **Patient** | Bertie Bridges |
| **Age** | 86 years old |
| **Gender** | Female |
| **Height/Weight** | 5'2" (157 cm) / 122 lbs (55.5 kg) |
| **BMI** | 22.3 (Within normal range) |
| **Setting** | Outpatient Primary Care / Geriatric Assessment Clinic |
| **Chief Complaint** | Progressive fatigue, exertional shortness of breath, and palpitations |
| **Case Year** | 2025/2026 |
**Key Differentiator:** This 86-year-old female patient is distinct from other i-Human cases. The critical
findings are a **systolic ejection murmur** (suggesting aortic stenosis) and an **acute episode of
tachycardia (HR 120)** during exercise that resolved with rest .
, ## 📝 Comprehensive SOAP Note
### S – SUBJECTIVE
**Chief Complaint (CC) – In Patient's Own Words:**
*"Yesterday I had a situation at water aerobics that was very alarming. I felt gradually more and more
short of breath, and then it got even more severe, my heart started racing. I was really scared. When my
instructor took my pulse it was 120 and regular. That's really unusual for me. It got better after I rested
for 30 minutes, but she insisted I get evaluated before she would let me back in the class."*
**History of Present Illness (HPI):**
Bertie Bridges is an 86-year-old female who presents to the outpatient clinic for evaluation after a
concerning episode during her regular water aerobics class. Her aquatic fitness instructor recommended
medical clearance before returning to activity.
**The Acute Episode:**
- **Setting:** During usual morning water aerobics class (attended twice weekly for 5 years without
incident)
- **Onset:** Gradual development of shortness of breath over 10-15 minutes
- **Progression:** Became severe enough to force cessation of exercise
- **Associated Symptoms:** Palpitations ("heart racing"), feeling scared, lightheadedness
- **Vital Sign During Episode:** Pulse 120 beats per minute, regular rhythm (per instructor assessment)
- **Resolution:** Symptoms subsided completely after resting poolside for approximately 30 minutes
- **Denies:** Chest pain, pressure, or tightness during or after the episode
**Chronic Symptoms (Past 3-4 weeks):**
- **Fatigue:** Reports a general sense of increased tiredness and lack of energy over the past "few
weeks," which she initially attributed to "just getting older." This fatigue is present upon waking and
Case Study: 65-Year-Old Female with
Trouble Sleeping | Advanced Health
Assessment Week 3 Comprehensive
SOAP Note by i-Human Clinical
Specialists | Pass Your Exam First
Attempt
,Based on the comprehensive 2025/2026 i-Human case study for **Bertie Bridges**, an 86-year-old
female presenting with progressive fatigue and an alarming episode of dyspnea with palpitations, here is
the optimized, complete SOAP note and management guide designed to help you pass on your first
attempt.
---
## 📋 Case Overview
| Category | Details |
| :--- | :--- |
| **Patient** | Bertie Bridges |
| **Age** | 86 years old |
| **Gender** | Female |
| **Height/Weight** | 5'2" (157 cm) / 122 lbs (55.5 kg) |
| **BMI** | 22.3 (Within normal range) |
| **Setting** | Outpatient Primary Care / Geriatric Assessment Clinic |
| **Chief Complaint** | Progressive fatigue, exertional shortness of breath, and palpitations |
| **Case Year** | 2025/2026 |
**Key Differentiator:** This 86-year-old female patient is distinct from other i-Human cases. The critical
findings are a **systolic ejection murmur** (suggesting aortic stenosis) and an **acute episode of
tachycardia (HR 120)** during exercise that resolved with rest .
, ## 📝 Comprehensive SOAP Note
### S – SUBJECTIVE
**Chief Complaint (CC) – In Patient's Own Words:**
*"Yesterday I had a situation at water aerobics that was very alarming. I felt gradually more and more
short of breath, and then it got even more severe, my heart started racing. I was really scared. When my
instructor took my pulse it was 120 and regular. That's really unusual for me. It got better after I rested
for 30 minutes, but she insisted I get evaluated before she would let me back in the class."*
**History of Present Illness (HPI):**
Bertie Bridges is an 86-year-old female who presents to the outpatient clinic for evaluation after a
concerning episode during her regular water aerobics class. Her aquatic fitness instructor recommended
medical clearance before returning to activity.
**The Acute Episode:**
- **Setting:** During usual morning water aerobics class (attended twice weekly for 5 years without
incident)
- **Onset:** Gradual development of shortness of breath over 10-15 minutes
- **Progression:** Became severe enough to force cessation of exercise
- **Associated Symptoms:** Palpitations ("heart racing"), feeling scared, lightheadedness
- **Vital Sign During Episode:** Pulse 120 beats per minute, regular rhythm (per instructor assessment)
- **Resolution:** Symptoms subsided completely after resting poolside for approximately 30 minutes
- **Denies:** Chest pain, pressure, or tightness during or after the episode
**Chronic Symptoms (Past 3-4 weeks):**
- **Fatigue:** Reports a general sense of increased tiredness and lack of energy over the past "few
weeks," which she initially attributed to "just getting older." This fatigue is present upon waking and
