I-Human Case 2025: Persistent Fatigue in Elderly Patient – Full SOAP Note Chana Kumar

I HUMAN CASE STUDY ELIAS LEON 57 YEARS OLD
REASON FOR ENCOUNTER HIGH BLOOD PRESSURE
RECHECK [SUSPECTED HYPERTENION] WITH A FULL
SOAP NOTE REAL 2025!!! ACTUAL




Patient Information

• Name: Elias Leon

• Age: 57 years

, • Gender: Male

• Height: 5’9” (175 cm)

• Weight: 195 lbs (88.6 kg)

• BMI: ~28.8 kg/m² (overweight)

• Location: Outpatient clinic with X-ray, ECG, and laboratory capabilities



Reason for Encounter

• Elevated blood pressure readings noted during routine check-up.



History of Present Illness (HPI)

• Mr. Leon reports he has been experiencing high blood pressure readings at home for the past 6
months.

• Denies chest pain, shortness of breath, palpitations, or dizziness.

• Occasional mild headaches in the mornings.

• No history of syncope or visual changes.

• Denies edema in feet or ankles.

• Reports difficulty managing weight and mild fatigue with exertion.

• No known target organ damage symptoms (no angina, heart failure symptoms, kidney issues).



Past Medical History

• Hypertension (diagnosed 6 months ago)

• Hyperlipidemia

• No history of diabetes mellitus

• No history of heart attack or stroke



Medications

• Currently taking OTC multivitamin

• No antihypertensive medications yet