i-Human Case Study | Harvey Hoya | High Blood Pressure Walden University | Advanced Health Assessment
I-Human Case Study
Harvey Hoya — High Blood Pressure
Graduate Premium Sick Visit Case: H&P + Dx
Advanced Health Assessment & Diagnostic Reasoning
Walden University
Nrnp 6531 / Nr 509 / Class 6512
Walden University — NRNP/NR Advanced Health Assessment & Diagnostic Reasoning Page 1
,i-Human Case Study | Harvey Hoya | High Blood Pressure Walden University | Advanced Health Assessment
PATIENT SNAPSHOT
Patient Name Harvey Hoya (H.H.)
Age 57 years old
Sex Male
Race/Ethnicity Hispanic
Height 5'9" (175 cm)
Weight 195.0 lb (88.6 kg)
BMI 28.7 (Overweight)
Occupation Construction worker (floor installation)
Reason for Encounter High blood pressure — referred from community health fair
Location Outpatient clinic with X-ray, ECG, and laboratory capabilities
Case Week Week #7
Course Advanced Health Assessment & Diagnostic Reasoning
Walden University — NRNP/NR Advanced Health Assessment & Diagnostic Reasoning Page 2
, i-Human Case Study | Harvey Hoya | High Blood Pressure Walden University | Advanced Health Assessment
SECTION I: SUBJECTIVE DATA
Chief Complaint (CC)
"I was recently at a health fair in my community where I had my blood pressure checked.
The nurse told me I should see a doctor because my pressure is too high. My wife was
concerned and made the appointment."
History of Present Illness (HPI)
H.H. is a 57-year-old overweight Hispanic male who works in construction installing floors. He
presents to the outpatient clinic following a referral from a community health fair, where a nurse
identified elevated blood pressure and recommended further evaluation. His wife, concerned
about the reading, scheduled today's appointment.
The patient reports a history of being told by a physician years ago that his blood pressure was "a
bit high" and that he should watch his diet. He did not follow up or initiate any treatment at that
time, as he felt well and dismissed the concern as insignificant. He is now presenting for the first
formal evaluation of hypertension.
In addition to elevated blood pressure, H.H. reports the following associated symptoms:
Headaches (OLDCARTS)
Onset Started several years ago; worsening in frequency over the past
few weeks
Location Behind the eyes; bilateral
Duration A couple of hours per episode
Character Dull, pressure-like headache
Aggravating Factors Morning hours; stress at work; increased workload
Relieving Factors Ibuprofen 800 mg provides temporary relief
Timing Predominantly in the mornings; intermittent
Severity 3–4 out of 10 on the numeric pain scale
Fatigue (OLDCARTS)
Onset Approximately 6 months ago
Character Daytime somnolence and generalized tiredness
Walden University — NRNP/NR Advanced Health Assessment & Diagnostic Reasoning Page 3
I-Human Case Study
Harvey Hoya — High Blood Pressure
Graduate Premium Sick Visit Case: H&P + Dx
Advanced Health Assessment & Diagnostic Reasoning
Walden University
Nrnp 6531 / Nr 509 / Class 6512
Walden University — NRNP/NR Advanced Health Assessment & Diagnostic Reasoning Page 1
,i-Human Case Study | Harvey Hoya | High Blood Pressure Walden University | Advanced Health Assessment
PATIENT SNAPSHOT
Patient Name Harvey Hoya (H.H.)
Age 57 years old
Sex Male
Race/Ethnicity Hispanic
Height 5'9" (175 cm)
Weight 195.0 lb (88.6 kg)
BMI 28.7 (Overweight)
Occupation Construction worker (floor installation)
Reason for Encounter High blood pressure — referred from community health fair
Location Outpatient clinic with X-ray, ECG, and laboratory capabilities
Case Week Week #7
Course Advanced Health Assessment & Diagnostic Reasoning
Walden University — NRNP/NR Advanced Health Assessment & Diagnostic Reasoning Page 2
, i-Human Case Study | Harvey Hoya | High Blood Pressure Walden University | Advanced Health Assessment
SECTION I: SUBJECTIVE DATA
Chief Complaint (CC)
"I was recently at a health fair in my community where I had my blood pressure checked.
The nurse told me I should see a doctor because my pressure is too high. My wife was
concerned and made the appointment."
History of Present Illness (HPI)
H.H. is a 57-year-old overweight Hispanic male who works in construction installing floors. He
presents to the outpatient clinic following a referral from a community health fair, where a nurse
identified elevated blood pressure and recommended further evaluation. His wife, concerned
about the reading, scheduled today's appointment.
The patient reports a history of being told by a physician years ago that his blood pressure was "a
bit high" and that he should watch his diet. He did not follow up or initiate any treatment at that
time, as he felt well and dismissed the concern as insignificant. He is now presenting for the first
formal evaluation of hypertension.
In addition to elevated blood pressure, H.H. reports the following associated symptoms:
Headaches (OLDCARTS)
Onset Started several years ago; worsening in frequency over the past
few weeks
Location Behind the eyes; bilateral
Duration A couple of hours per episode
Character Dull, pressure-like headache
Aggravating Factors Morning hours; stress at work; increased workload
Relieving Factors Ibuprofen 800 mg provides temporary relief
Timing Predominantly in the mornings; intermittent
Severity 3–4 out of 10 on the numeric pain scale
Fatigue (OLDCARTS)
Onset Approximately 6 months ago
Character Daytime somnolence and generalized tiredness
Walden University — NRNP/NR Advanced Health Assessment & Diagnostic Reasoning Page 3
