I-HUMAN CLINICAL CASE STUDY WEEK 7 – 57-
YEAR-OLD MALE WITH UNCONTROLLED
HYPERTENSION AND DYSLIPIDEMIA | STEP-BY-
STEP EVIDENCE-BASED CARE
COMPREHENSIVE MEDICAL CASE STUDY: FELIPE GARCIA
SECTION 1: CASE IDENTIFICATION & ADMINISTRATIVE DATA
Patient Demographics:
• Name: Felipe Esteban Garcia
• Age: 57 years
• Date of Birth: April 15, 1967
• Sex: Male
• Race/Ethnicity: Hispanic/Latino
• Marital Status: Married
• Occupation: Construction Project Manager
• Insurance: Private PPO (Aetna)
• Primary Language: English (fluent), Spanish (native)
, • Religion: Roman Catholic
• Advance Directives: None on file
• Date of Encounter: October 26, 2024
• Time of Encounter: 10:15 AM
• Type of Visit: Established patient, follow-up
• Referring Provider: Self-referred
• Chief Complaint: "My blood pressure is still too high"
SECTION 2: SUBJECTIVE DATA
2.1 Chief Complaint (CC)
"Uncontrolled blood pressure readings at home for 3 months"
2.2 History of Present Illness (HPI)
OPQRST Format:
• Onset: Gradual recognition over past 3 months through home monitoring
• Provocation/Palliation: Worse with work stress, alcohol consumption. No clear
palliation noted.
• Quality: Asymptomatic hypertension
• Radiation: Not applicable
• Severity: Stage 2 hypertension consistently (150-162/92-98 mmHg)
• Timing: Persistent throughout day, no diurnal pattern noted
OLDCARTS Format:
• Onset: 3 months of persistent elevation
• Location: Systemic
• Duration: Constant finding
• Character: Asymptomatic elevation
• Aggravating Factors: Stress, high-sodium meals, alcohol intake, missed medications
, • Relieving Factors: None identified
• Temporal Pattern: No specific time pattern
• Severity: Stage 2 hypertension
Detailed Narrative:
Mr. Garcia is a 57-year-old Hispanic male with established diagnoses of essential hypertension
(10 years) and mixed dyslipidemia (8 years) who presents for follow-up of persistently elevated
home blood pressure readings over the past 3 months. Despite being prescribed Lisinopril 20
mg daily and Atorvastatin 20 mg daily, his average home readings range from 150-162/92-98
mmHg. He admits to approximately 70% adherence with Lisinopril, missing doses 2-3 times
weekly due to forgetfulness during hectic morning routines. He reports good adherence to
Atorvastatin. He denies classic hypertensive symptoms including headache, vision changes,
chest pain, or palpitations. He does endorse non-specific fatigue and mild exertional dyspnea
when climbing two flights of stairs at work, which he attributes to deconditioning. Lifestyle
factors include a high-sodium diet with frequent takeout meals, daily alcohol consumption (2-3
glasses of red wine nightly, 4-5 nights/week), sedentary lifestyle, and significant occupational
stress as a project manager. He expresses motivation for better control due to family history of
premature coronary artery disease. No recent medication changes, illness, or stressful life
events reported.
2.3 Review of Systems (ROS)
Complete 14-Point Review:
Constitutional:
• Fatigue
• Fever, chills, night sweats
• Unintentional weight change
• Reports feeling "stressed and tired"
HEENT:
• Headache, dizziness, lightheadedness
• Visual changes, blurred vision, floaters
• Hearing changes, tinnitus
• Sinus congestion, epistaxis
, • Sore throat, dysphagia
• Dentition: Last dental exam 1 year ago
Cardiovascular:
• Chest pain, pressure, tightness
• Palpitations, irregular heartbeat
• Dyspnea on exertion (climbing 2 flights stairs)
• Orthopnea, paroxysmal nocturnal dyspnea
• Peripheral edema
• Claudication, leg cramps
• Home Monitoring: Consistent Stage 2 HTN readings
Respiratory:
• Cough, sputum production
• Wheezing, stridor
• Hemoptysis
• Shortness of breath at rest
• Mild DOE as above
Gastrointestinal:
• Abdominal pain, discomfort
• Nausea, vomiting
• Diarrhea, constipation
• Melena, hematochezia
• Dyspepsia, heartburn
• Dietary Pattern: High in processed foods, takeout meals
Genitourinary:
• Dysuria, frequency, urgency
YEAR-OLD MALE WITH UNCONTROLLED
HYPERTENSION AND DYSLIPIDEMIA | STEP-BY-
STEP EVIDENCE-BASED CARE
COMPREHENSIVE MEDICAL CASE STUDY: FELIPE GARCIA
SECTION 1: CASE IDENTIFICATION & ADMINISTRATIVE DATA
Patient Demographics:
• Name: Felipe Esteban Garcia
• Age: 57 years
• Date of Birth: April 15, 1967
• Sex: Male
• Race/Ethnicity: Hispanic/Latino
• Marital Status: Married
• Occupation: Construction Project Manager
• Insurance: Private PPO (Aetna)
• Primary Language: English (fluent), Spanish (native)
, • Religion: Roman Catholic
• Advance Directives: None on file
• Date of Encounter: October 26, 2024
• Time of Encounter: 10:15 AM
• Type of Visit: Established patient, follow-up
• Referring Provider: Self-referred
• Chief Complaint: "My blood pressure is still too high"
SECTION 2: SUBJECTIVE DATA
2.1 Chief Complaint (CC)
"Uncontrolled blood pressure readings at home for 3 months"
2.2 History of Present Illness (HPI)
OPQRST Format:
• Onset: Gradual recognition over past 3 months through home monitoring
• Provocation/Palliation: Worse with work stress, alcohol consumption. No clear
palliation noted.
• Quality: Asymptomatic hypertension
• Radiation: Not applicable
• Severity: Stage 2 hypertension consistently (150-162/92-98 mmHg)
• Timing: Persistent throughout day, no diurnal pattern noted
OLDCARTS Format:
• Onset: 3 months of persistent elevation
• Location: Systemic
• Duration: Constant finding
• Character: Asymptomatic elevation
• Aggravating Factors: Stress, high-sodium meals, alcohol intake, missed medications
, • Relieving Factors: None identified
• Temporal Pattern: No specific time pattern
• Severity: Stage 2 hypertension
Detailed Narrative:
Mr. Garcia is a 57-year-old Hispanic male with established diagnoses of essential hypertension
(10 years) and mixed dyslipidemia (8 years) who presents for follow-up of persistently elevated
home blood pressure readings over the past 3 months. Despite being prescribed Lisinopril 20
mg daily and Atorvastatin 20 mg daily, his average home readings range from 150-162/92-98
mmHg. He admits to approximately 70% adherence with Lisinopril, missing doses 2-3 times
weekly due to forgetfulness during hectic morning routines. He reports good adherence to
Atorvastatin. He denies classic hypertensive symptoms including headache, vision changes,
chest pain, or palpitations. He does endorse non-specific fatigue and mild exertional dyspnea
when climbing two flights of stairs at work, which he attributes to deconditioning. Lifestyle
factors include a high-sodium diet with frequent takeout meals, daily alcohol consumption (2-3
glasses of red wine nightly, 4-5 nights/week), sedentary lifestyle, and significant occupational
stress as a project manager. He expresses motivation for better control due to family history of
premature coronary artery disease. No recent medication changes, illness, or stressful life
events reported.
2.3 Review of Systems (ROS)
Complete 14-Point Review:
Constitutional:
• Fatigue
• Fever, chills, night sweats
• Unintentional weight change
• Reports feeling "stressed and tired"
HEENT:
• Headache, dizziness, lightheadedness
• Visual changes, blurred vision, floaters
• Hearing changes, tinnitus
• Sinus congestion, epistaxis
, • Sore throat, dysphagia
• Dentition: Last dental exam 1 year ago
Cardiovascular:
• Chest pain, pressure, tightness
• Palpitations, irregular heartbeat
• Dyspnea on exertion (climbing 2 flights stairs)
• Orthopnea, paroxysmal nocturnal dyspnea
• Peripheral edema
• Claudication, leg cramps
• Home Monitoring: Consistent Stage 2 HTN readings
Respiratory:
• Cough, sputum production
• Wheezing, stridor
• Hemoptysis
• Shortness of breath at rest
• Mild DOE as above
Gastrointestinal:
• Abdominal pain, discomfort
• Nausea, vomiting
• Diarrhea, constipation
• Melena, hematochezia
• Dyspepsia, heartburn
• Dietary Pattern: High in processed foods, takeout meals
Genitourinary:
• Dysuria, frequency, urgency
