"I Human Felipe Garcia NR 509 week 5 Case Study High Blood Pressure"

NR 509 WEEK 5 IHUMAN Case v v v v v




Study: Felipe Garcia Complete With v v v v




SOAP Note v v




NR 509 WEEK 5 IHUMAN
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Case Study: Felipe Garcia
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v Assessment
Felipe Garcia is a 52-year-old male presenting with symptoms of headache
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and dizziness, likely related to newly diagnosed hypertension. His elevated
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BP, family history, and lifestyle factors support a diagnosis of primary
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hypertension. Initial management will focus on lifestyle modifications and
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possibly pharmacologic therapy if BP remains elevated. Patient education
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and follow-up are critical to ensure adherence and prevent complications.
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,Patient Name: Felipe Garcia v v v



Age: 52 v



Gender: Male v



Chief Complaint: "I’ve been feeling dizzy and have a headache for the
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past few days."
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HPI (History of Present Illness)
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1: "Can you tell me more about your symptoms?"
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Felipe Garcia: "Sure. I’ve had a headache for about three days now. It’s
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mostly in the back of my head, and it feels like pressure. I’ve also been
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feeling dizzy, especially when I stand up quickly. I noticed my vision gets a
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little blurry sometimes too."
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2: "Have you checked your blood pressure recently?"
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Felipe Garcia: "Yes, I checked it at the pharmacy two days ago, and it was
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160/95. I was surprised because I’ve never had high blood pressure before."
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3: "Do you have any other symptoms, like chest pain, shortness of
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breath, or nausea?"
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Felipe Garcia: "No, none of that. Just the headache and dizziness."
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4: "Have you had any recent stress or changes in your life?" Felipe
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Garcia: "Well, I’ve been under a lot of stress at work lately. I’ve also been
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eating out more and not exercising as much as I should."
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5: "Do you have a family history of high blood pressure or heart
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disease?"
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Felipe Garcia: "Yes, my father had high blood pressure, and he passed
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away from a heart attack when he was 60."
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6: "Do you smoke, drink alcohol, or use any recreational drugs?"
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Felipe Garcia: "I don’t smoke or use drugs, but I do drink a couple of
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beers on the weekends."
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7: "Are you taking any medications or supplements?"
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Felipe Garcia: "No, I’m not taking anything right now."
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, Past Medical History (PMH)
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 No known history of hypertension, diabetes, or heart disease.
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 No previous surgeries or hospitalizations.
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Family History (FH)
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 Father: Hypertension, died of myocardial infarction at age 60.
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 Mother: Alive, has type 2 diabetes.
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Social History (SH)
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 Works as a manager at a manufacturing plant.
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 Drinks alcohol socially (2-3 beers per week).
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 Denies tobacco or illicit drug use.
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 Sedentary lifestyle; reports minimal physical activity.
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 Diet high in processed foods and sodium.
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