57-Year-Old Male I-Human Case Study: Felipe Garcia | NR
509 Week 5 | Reason for Encounter: High Blood Pressure
| Comprehensive Medical Analysis with HPI, PE,
Differential Diagnosis & Treatment Plan
, Patient Information
• Age: 57 years
• Sex: Male
• Occupation: Full-time worker, married, has adult son
• Lifestyle: Sedentary, smoking ~1 pack/day for
35 years, occasional weekend alcohol,
high-salt/processed diet, regular coffee, nightly
snoring
History of Present Illness (HPI)
• Chief complaint: Elevated blood pressure
documented after health fair screening; wife
prompted follow-up
• Symptoms: Frequent headaches, mild dizziness,
fatigue, possible sleep apnea signs (snoring,
tiredness)
• Medication/history: Previously advised lifestyle
modifications and BP monitoring but non-adherent;
occasional ibuprofen & omeprazole for gastritis; no
diabetes or CKD
, Past Medical & Family History
• PMH: Mild gastritis, recurring headaches
• Medications: Over-the-counter ibuprofen,
omeprazole
• Family history: Father had hypertension and died of
stroke at age 62; mother diabetic with hypertension
Review of Systems
• HEENT: Headaches, dizziness
• Cardiovascular/Respiratory: No chest pain or
dyspnea
• Genitourinary: Possible nocturia (frequency every 1–
2 hrs)
• Neurologic: No visual changes, syncope, or focal
deficits
Physical Exam
• Vitals: BP ~178/98 mmHg (right arm); BMI ~28.8
(overweight) (docsity.com)
509 Week 5 | Reason for Encounter: High Blood Pressure
| Comprehensive Medical Analysis with HPI, PE,
Differential Diagnosis & Treatment Plan
, Patient Information
• Age: 57 years
• Sex: Male
• Occupation: Full-time worker, married, has adult son
• Lifestyle: Sedentary, smoking ~1 pack/day for
35 years, occasional weekend alcohol,
high-salt/processed diet, regular coffee, nightly
snoring
History of Present Illness (HPI)
• Chief complaint: Elevated blood pressure
documented after health fair screening; wife
prompted follow-up
• Symptoms: Frequent headaches, mild dizziness,
fatigue, possible sleep apnea signs (snoring,
tiredness)
• Medication/history: Previously advised lifestyle
modifications and BP monitoring but non-adherent;
occasional ibuprofen & omeprazole for gastritis; no
diabetes or CKD
, Past Medical & Family History
• PMH: Mild gastritis, recurring headaches
• Medications: Over-the-counter ibuprofen,
omeprazole
• Family history: Father had hypertension and died of
stroke at age 62; mother diabetic with hypertension
Review of Systems
• HEENT: Headaches, dizziness
• Cardiovascular/Respiratory: No chest pain or
dyspnea
• Genitourinary: Possible nocturia (frequency every 1–
2 hrs)
• Neurologic: No visual changes, syncope, or focal
deficits
Physical Exam
• Vitals: BP ~178/98 mmHg (right arm); BMI ~28.8
(overweight) (docsity.com)
