SNAPPS History Taking and Physical Examination Case Study
This paper presents a clinical case study using the SNAPPS learning framework to document history taking and physical examination for a 61-year-old male presenting with uncontrolled hypertension. The paper covers a detailed HPI using OLDCARTS, a pertinent review of systems, physical examination findings, and narrowed differential diagnoses including hypercholesterolemia, rheumatoid arthritis, and peptic ulcer disease. A treatment plan is proposed alongside referral recommendations. A self-directed learning reflection concludes the paper, connecting clinical reasoning, patient-centered care, and the student's professional development as a nurse practitioner trainee.
- Chief Complaint and History of Present Illness: 61-year-old male with uncontrolled hypertension and multisystem symptoms
- Review of Systems: Pertinent multi-system review findings across organ systems
- Physical Examination Findings: Key abnormal findings from head-to-toe physical exam
- Differential Diagnoses and Analysis: Hypercholesterolemia, rheumatoid arthritis, and peptic ulcer considered
- Treatment Plan and Follow-Up: Medication continuation, lifestyle modifications, and referrals
- Self-Directed Learning Reflection: Student reflects on clinical reasoning and professional growth
✍️ How to write this paper — guide, tools & examples ▾
What makes this paper effective
- The paper applies the structured SNAPPS framework consistently, guiding the reader through summarization, narrowing, analysis, probing, and planning in a logical clinical sequence.
- The OLDCARTS format for the HPI is faithfully executed, capturing onset, location, duration, character, aggravating/alleviating factors, radiation, timing, and associated symptoms in an organized manner.
- The self-directed learning reflection is candid and connects clinical skills to the student's developing professional identity, demonstrating metacognitive awareness appropriate for a graduate-level clinical course.
Key academic technique demonstrated
The paper demonstrates systematic clinical reasoning by linking the patient's past medical history, social history, and family history to each differential diagnosis. Rather than listing diagnoses arbitrarily, the student explicitly justifies each candidate diagnosis with supporting evidence from the case — a hallmark of evidence-informed clinical decision-making.
Structure breakdown
The paper opens with patient identification and the chief complaint, then moves through the HPI (OLDCARTS), a multi-system review of systems, physical examination findings, narrowed differentials with analysis, a probing section recommending specialist referrals, a concrete treatment plan with prescriptions, and closes with a personal self-directed learning reflection. This mirrors the SNAPPS model's six sequential steps and is well-suited to a graduate-level clinical clerkship assignment.
Chief Complaint and History of Present Illness
This patient is a 61-year-old male who presents to the clinic with a chief complaint of uncontrolled blood pressure for a follow-up visit.
Using the SNAPPS framework and OLDCARTS method for the HPI, the onset of symptoms was one year ago, and the condition has been progressively worsening. Lightheadedness and muscle weakness are constant. He experiences a sharp, throbbing headache in the left temporal region, which he rates at 7/10 on the Numeric Pain Rating Scale (NPRS). The headache is progressive and is accompanied by light sensitivity, nausea, and vomiting. Loss of consciousness associated with the headache is negative. He reports no convulsions but is positive for visual changes; other special senses are unremarkable except for a burning sensation in his eyes. He experiences spasmodic pain and is unable to eat during headache episodes.
He reports experiencing dry mouth, which makes it difficult to feed properly due to pain while swallowing. The patient also experiences joint pain in both the lower and upper limbs, which he graded 9/10 in severity. Antipyretics and analgesics alleviate the headache, and joint pain was similarly alleviated by NSAIDs. The joint pain is aggravated by walking or lifting heavy objects, while the headache is aggravated by upright posture. Associated symptoms include chills, general body weakness, malaise, night sweats, fever, and insomnia due to pain.
His past medical history reveals that approximately one year ago he was diagnosed with rheumatoid arthritis. He reports being placed on corticosteroid therapy, which markedly alleviated his symptoms, followed by methotrexate administration, which proved ineffective up to the time of this visit. The patient also reported having had hip replacement surgery approximately five years ago. He reports completing his vaccinations when young, including the influenza vaccine.
Current medications include Bystolic 40 mg daily, hydralazine 25 mg twice daily, and losartan daily for hypertension, as well as omeprazole 20 mg daily, sildenafil 100 mg, and atorvastatin calcium 20 mg. The patient has no known drug allergies.
Regarding social history, the patient shares a bottle of wine with his wife during their daily evening dinner, exercises regularly, and has not regulated fat or salt consumption. His family history is notable: his father died from diabetes and hypertension, his mother lives with osteoporosis and hypothyroidism, and he has three brothers and one sister with no known chronic illnesses.
Review of Systems
The pertinent review of systems (ROS) findings are as follows:
General: The patient appeared febrile and tired.
Head and face: No pain, loss of sensation, or traumatic injuries reported.
Eyes: Positive for episodes of burning sensation and visual changes; negative for inflammation and infection.
Neck: No masses; positive for enlarged pre-auricular lymph nodes.
Ears: Negative for infections, inflammation, or changes in hearing.
Nose and sinuses: No pain, obstruction, or discharge; positive for epistaxis.
Mouth and throat: No dental problems; positive for dysphagia, odynophagia, and dry mouth.
Skin: Negative for easy bruising, discoloration, hair loss, and dry skin; positive signs noted in the pre-auricular region.
Central nervous system: Positive for lightheadedness, headaches, fainting episodes, dizziness, gait disturbances, and slight confusion.
Respiratory system: Lung sounds clear; no cough, shortness of breath, wheezing, dyspnea, tachypnea, nasal congestion, or other respiratory distress.
Cardiovascular system: Negative for chest pain, dyspnea, palpitations, lower extremity edema, tachycardia, increased heart rate, or shortness of breath; overall normal breathing patterns.
Gastrointestinal system: Negative for abdominal distention, hemoptysis, abdominal pain, vomiting, dyspepsia, and dysphagia; slight decline in appetite noted.
Genitourinary system: Positive for hematuria and dysuria; negative for urinary incontinence; urine was of normal color, volume, and frequency.
Musculoskeletal system: Positive for joint pain, fatigue, general body weakness, and mild back pain.
Physical Examination Findings
The pertinent physical examination (PE) findings are as follows:
General: Blood pressure was markedly elevated.
Throat: Enlarged thyroid gland noted.
Eyes: Distended veins and mild hemorrhages observed.
Heart: Arrhythmias noted, unequal blood pressure in both arms, and tachycardia present.
Lungs: Rales noted; normal breathing pattern.
Abdomen: Normal on palpation and percussion.
Lower extremities: Normal.
Musculoskeletal: Marked muscular atrophy, delayed motor reflex, and slightly delayed perception of pain, temperature, and light touch.
Hematological: Marked deficit in hemoglobin count.
Vital signs: BP 170/100 mmHg, HR 86 bpm, RR 82.50 bpm, SpO₂ 93% on room air, weight 84 kg, height 156 cm.
Always verify citation format against your institution’s current style guide requirements.