CASE STUDY GRADED A+ 2026
UPDATED LATEST
, I-human Note Template
Patient Information: H.H., 57-
years-old, Male, Hispanic
Subjective:
CC (chief complaint) High blood pressure
HPI: H.H. is a 57-year-old overweight Hispanic construction worker who presents for evaluation of an
elevated blood pressure reading at a recent local health fair. He reports intermittent mild headaches,
and interrupted sleep with snoring. Headaches started a few weeks ago, mostly occur in the mornings
and are intermittent and mild. Associated symptoms with the headaches are the patient has interrupted
sleep with snoring and is fatigued during the day. Headaches are 3-4/10 on the pain scale. The patient
takes 800mg of ibuprofen three times a day for 2 days during the week to help with the headaches.
Physical examination is notable BP 172/94 L and 178/98 R; laterally displaced PMI; and funduscopic
findings of A-V nicking. Was told he had elevated BP in the past, but took no action. PF is positive for
hypertension and related complications.
Current Medications:
• Ibuprofen 800mg TID for 2-3 times per week for headaches
• Omeprazole 1 tablet daily for gastritis
Allergies: Denies environmental, food, or medication allergies
Pertinent PMHx:
Immunizations:
• Hep B (3 doses)