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I- HUMAN CASE STUDY FOR 56-YEAR-OLD
FEMALE - REASON FOR ENCOUNTER: BLOOD-
PRESSURE RECHECK| WEEK #7 (CLASS 6512)
SETTING: OUTPATIENT CLINIC (X-RAY, ECG, LAB
SERVICES AVAILABLE) LATEST UPDATE WITH A
SOAP NOTE
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Case title & summary:
Blood-pressure recheck for a 56-year-old woman with previously elevated office
readings. This case emphasizes accurate BP measurement, differentiation between
sustained and white-coat hypertension, cardiovascular risk stratification, initial
workup for secondary causes, treatment initiation/optimization, and safe follow-up
consistent with current guideline recommendations. (Ahajournals)
Reason for encounter:
Follow-up visit to re-check blood pressure after an elevated office reading 1 week
ago.
Patient demographics:
• Age: 56 years
• Sex: Female
• Height: 162 cm (5′4″)
• Weight: 82 kg (181 lb) — BMI ≈ 31.3 (obese)
• Occupation: Administrative assistant (mostly sedentary)
Case mode: Learning mode
Clinic capabilities: Office BP, ECG, point-of-care labs, urine studies, X-ray (if
indicated), referral access for ABPM and echo.
Attempts allowed: Unlimited (learning)
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2. Chief Complaint (CC)
“I’m here to have my blood pressure checked again — my reading at my last
appointment was high and I’m worried.”
3. History of Present Illness (HPI)
• Patient reports an office BP of 152/96 mmHg at a routine visit 7 days ago
(single reading, cuff appropriate size uncertain). She was advised to return
for recheck and to bring any home BP logs.
• She feels generally well but notes occasional morning headaches and mild
fatigue over the past month. No chest pain, shortness of breath, palpitations,
dizziness, syncope, or visual changes.
• She reports intermittent home BP checks over past week: values ranged from
135–148/82–94 mmHg (handwritten log). She is not currently taking anti-
hypertensive medication.
• Lifestyle: sedentary job, eats out 3–4 times/week, high-salt processed foods,
drinks ~2 caffeinated beverages/day, denies tobacco, drinks 2–3 alcoholic
drinks per week. Sleep 6–7 hours/night.
• Recent life stressors but no medication changes. No over-the-counter
decongestant or chronic NSAID use reported.
4. Past Medical History (PMH)
I- HUMAN CASE STUDY FOR 56-YEAR-OLD
FEMALE - REASON FOR ENCOUNTER: BLOOD-
PRESSURE RECHECK| WEEK #7 (CLASS 6512)
SETTING: OUTPATIENT CLINIC (X-RAY, ECG, LAB
SERVICES AVAILABLE) LATEST UPDATE WITH A
SOAP NOTE
,2|Page
Case title & summary:
Blood-pressure recheck for a 56-year-old woman with previously elevated office
readings. This case emphasizes accurate BP measurement, differentiation between
sustained and white-coat hypertension, cardiovascular risk stratification, initial
workup for secondary causes, treatment initiation/optimization, and safe follow-up
consistent with current guideline recommendations. (Ahajournals)
Reason for encounter:
Follow-up visit to re-check blood pressure after an elevated office reading 1 week
ago.
Patient demographics:
• Age: 56 years
• Sex: Female
• Height: 162 cm (5′4″)
• Weight: 82 kg (181 lb) — BMI ≈ 31.3 (obese)
• Occupation: Administrative assistant (mostly sedentary)
Case mode: Learning mode
Clinic capabilities: Office BP, ECG, point-of-care labs, urine studies, X-ray (if
indicated), referral access for ABPM and echo.
Attempts allowed: Unlimited (learning)
, 3|Page
2. Chief Complaint (CC)
“I’m here to have my blood pressure checked again — my reading at my last
appointment was high and I’m worried.”
3. History of Present Illness (HPI)
• Patient reports an office BP of 152/96 mmHg at a routine visit 7 days ago
(single reading, cuff appropriate size uncertain). She was advised to return
for recheck and to bring any home BP logs.
• She feels generally well but notes occasional morning headaches and mild
fatigue over the past month. No chest pain, shortness of breath, palpitations,
dizziness, syncope, or visual changes.
• She reports intermittent home BP checks over past week: values ranged from
135–148/82–94 mmHg (handwritten log). She is not currently taking anti-
hypertensive medication.
• Lifestyle: sedentary job, eats out 3–4 times/week, high-salt processed foods,
drinks ~2 caffeinated beverages/day, denies tobacco, drinks 2–3 alcoholic
drinks per week. Sleep 6–7 hours/night.
• Recent life stressors but no medication changes. No over-the-counter
decongestant or chronic NSAID use reported.
4. Past Medical History (PMH)
