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