Arthritis in a 66-Year-Old Female: A
Simulated i-Human Case with Back Pain |
COMPLETE A+ SOLUTION | SOAP Notes,
HPI, ROS, Physical Exam, Imaging,
Differential Diagnosis & Evidence-Based
Management Plan
,Case Title (Understandable)
66-Year-Old Woman with Shortness of Breath and Chest
Tightness
1. Patient Introduction
Mrs. Eleanor Vance is a 66-year-old female who presents to the
outpatient clinic with a 2-day history of progressive shortness of
breath and intermittent chest tightness. She has a past medical
history of hypertension and osteoporosis. She is accompanied by
her daughter. The clinic has on-site x-ray and laboratory
capabilities.
2. Patient Biodata
Attribute Details
Age 66 years
Sex Female
Height 150 cm (4'11")
Weight 47.7 kg (105 lb)
BMI 21.2 (Normal)
, Attribute Details
Ethnicity Caucasian
Occupation Retired teacher
Living situation Lives alone in a two-story home
Code Status Full code
Primary language English
3. History of Present Illness (HPI)
Onset: 2 days ago, gradually worsening over 24 hours.
Location: Shortness of breath – diffuse; chest tightness –
substernal, non-radiating.
Quality:
• Shortness of breath: "feels like I can't get enough air in"
• Chest tightness: "a heavy pressure, not sharp"
Severity:
• SOB: 5/10 at rest, 8/10 with walking to bathroom
• Chest tightness: 4/10 intermittent
Timing:
• SOB: constant for past 24 hours, worse with any exertion