OLD MALE WITH UNCONTROLLED HYPERTENSION
DYSLIPIDEMIA AND PREDIABETES IN OUTPATIENT
CLINIC
,Patient Information
Name: Felipe Garcia
Age: 57 years
Gender: Male
Height: 5’9” (175 cm)
Weight: 198 lbs (89.8 kg)
BMI: 29.2 kg/m² (overweight)
Encounter Type: Outpatient clinic visit
Reason for Encounter: Evaluation of persistently elevated blood pressure
Setting: Outpatient clinic with laboratory and ECG capabilities
Felipe Garcia is a 57-year-old male with a known history of essential
hypertension, hyperlipidemia, and prediabetes, presenting to the clinic for
follow-up evaluation. He expresses concern about persistent elevated blood
pressure readings despite taking his medications regularly, although he admits
occasional missed doses. He reports headaches, occasional dizziness, and
fatigue, which he attributes to high blood pressure. He also notes challenges
adhering to lifestyle modifications, particularly diet and physical activity.
, Chief Complaint
“I’ve been taking my medications, but my blood pressure is still high and I
sometimes feel dizzy.”