NR509 Week 5 iHuman Case Study
Anselmo Lopez 57 y.o. M 5’9” 195.0 lbs. (88.6kg)
Reason for encounter: High Blood Pressure
**This case uses AHA/ACC guidelines. Please reference those as needed for evidence-
based case completion
Chief Complaint: Concern his blood pressure is high after attending a community health
fair.
Ask 2 open ended Questions: “How can I help you today?” “Any other symptoms or
concerns?”
History of Present Illness (HPI): A.L. is a 57-year-old male presenting for evaluation of
elevated blood pressure noted incidentally at a recent community health fair, where his
reading was reportedly 170/92 mmHg. He denies any associated symptoms such as
headache, chest pain, shortness of breath, palpitations, dizziness, or vision changes. He is
unsure how long his blood pressure has been elevated but recalls being told years ago by a
physician that his pressure was “a bit high” and that he should watch his diet. At the time,
he did not pursue further evaluation or treatment as he felt well. He does not currently
monitor his blood pressure and has not seen a regular healthcare provider until this visit.
He denies any known factors that exacerbate or alleviate his blood pressure and has not
received any previous treatment for hypertension.
He reports no current symptoms of concern and feels generally well. He does report a
history of right knee pain, which he attributes to a prior ACL injury and surgery following a
sports-related trauma. He uses OTC ibuprofen as needed (200 mg, 2–4 tablets, a couple of
times a day on a few days per week), which he reports helps relieve his knee pain. He also
takes OTC omeprazole as directed for occasional heartburn, especially after spicy meals.
He denies any chest pain, dyspnea, palpitations, or malaise.
His past medical history is otherwise unremarkable aside from episodic gastritis/acid
reflux and chronic right knee discomfort. He denies having a primary care provider and this
is his first medical evaluation in several years.
Family history is significant for hypertension in his brother and uncle, diabetes in his
mother and maternal grandmother, and cardiovascular disease with premature death on
the paternal side — his father died of a stroke at age 62 and his paternal grandfather of a
heart attack at age 52.
, Social history reveals a 35-year history of tobacco use at approximately one pack per day.
He reports occasional weekend alcohol consumption and denies any illicit drug use. Diet
consists of fast food lunches, frequent Tex-Mex dinners, and daily coffee intake. He works
in construction, primarily in flooring and cabinetry, and reports no current psychosocial
stressors. He is able to attend clinic appointments and is motivated to address his health
concerns, particularly due to his wife's worries.
Question Response
How can I help you today? I was recently at a health fair in my community where
I had my BP checked. The nurse told me that I should
see a doctor because my pressure is too high. I think
she said 170/92 or something like that.
Do you have any other symptoms or No
concerns we should discuss?
When did your high BP start? I don’t know. I remember some doctor years ago
saying I could watch my diet because my pressure
was a bit high…but I felt well and really didn’t pay him
much attention.
Does anything make your high BP better or I don’t know. I haven’t been paying any attention
worse?
What treatments have you had for your I don’t have a regular doc. This is really my first visit
high BP?
What treatments have you had for the pain Ibuprofen
in your knees?
Does anything make the pin in your knees Ibuprofen makes it better
better or worse?
Can you tell me about any current or past Other than the high BP. I don’t think I really have any.
medical problems you have had? Maybe just a little bit of acid stomach. Somebody told
me I had gastritis once. And I have achy knees.
Have you had any significant traumatic I guess when I twisted my knee that was pretty
injuries or accidents? significant. I ended up getting surgery. My soccer
game has never been the same since.
Any previous medical, surgical, or dental I had my ACL repaired in my right knee. Nothing else.
procedures?
Are your immunizations up to date? I got all the childhood stuff. Nothing since.
Have you had the flu shot this year? No.
Have you had a colonoscopy? Nope
Are you taking any OTC or herbal Omeprazole OTC for my stomach. I get reflux
medications? sometimes after a spicy dinner, but I take that like the
box says and it takes care of the heartburn, no
Anselmo Lopez 57 y.o. M 5’9” 195.0 lbs. (88.6kg)
Reason for encounter: High Blood Pressure
**This case uses AHA/ACC guidelines. Please reference those as needed for evidence-
based case completion
Chief Complaint: Concern his blood pressure is high after attending a community health
fair.
Ask 2 open ended Questions: “How can I help you today?” “Any other symptoms or
concerns?”
History of Present Illness (HPI): A.L. is a 57-year-old male presenting for evaluation of
elevated blood pressure noted incidentally at a recent community health fair, where his
reading was reportedly 170/92 mmHg. He denies any associated symptoms such as
headache, chest pain, shortness of breath, palpitations, dizziness, or vision changes. He is
unsure how long his blood pressure has been elevated but recalls being told years ago by a
physician that his pressure was “a bit high” and that he should watch his diet. At the time,
he did not pursue further evaluation or treatment as he felt well. He does not currently
monitor his blood pressure and has not seen a regular healthcare provider until this visit.
He denies any known factors that exacerbate or alleviate his blood pressure and has not
received any previous treatment for hypertension.
He reports no current symptoms of concern and feels generally well. He does report a
history of right knee pain, which he attributes to a prior ACL injury and surgery following a
sports-related trauma. He uses OTC ibuprofen as needed (200 mg, 2–4 tablets, a couple of
times a day on a few days per week), which he reports helps relieve his knee pain. He also
takes OTC omeprazole as directed for occasional heartburn, especially after spicy meals.
He denies any chest pain, dyspnea, palpitations, or malaise.
His past medical history is otherwise unremarkable aside from episodic gastritis/acid
reflux and chronic right knee discomfort. He denies having a primary care provider and this
is his first medical evaluation in several years.
Family history is significant for hypertension in his brother and uncle, diabetes in his
mother and maternal grandmother, and cardiovascular disease with premature death on
the paternal side — his father died of a stroke at age 62 and his paternal grandfather of a
heart attack at age 52.
, Social history reveals a 35-year history of tobacco use at approximately one pack per day.
He reports occasional weekend alcohol consumption and denies any illicit drug use. Diet
consists of fast food lunches, frequent Tex-Mex dinners, and daily coffee intake. He works
in construction, primarily in flooring and cabinetry, and reports no current psychosocial
stressors. He is able to attend clinic appointments and is motivated to address his health
concerns, particularly due to his wife's worries.
Question Response
How can I help you today? I was recently at a health fair in my community where
I had my BP checked. The nurse told me that I should
see a doctor because my pressure is too high. I think
she said 170/92 or something like that.
Do you have any other symptoms or No
concerns we should discuss?
When did your high BP start? I don’t know. I remember some doctor years ago
saying I could watch my diet because my pressure
was a bit high…but I felt well and really didn’t pay him
much attention.
Does anything make your high BP better or I don’t know. I haven’t been paying any attention
worse?
What treatments have you had for your I don’t have a regular doc. This is really my first visit
high BP?
What treatments have you had for the pain Ibuprofen
in your knees?
Does anything make the pin in your knees Ibuprofen makes it better
better or worse?
Can you tell me about any current or past Other than the high BP. I don’t think I really have any.
medical problems you have had? Maybe just a little bit of acid stomach. Somebody told
me I had gastritis once. And I have achy knees.
Have you had any significant traumatic I guess when I twisted my knee that was pretty
injuries or accidents? significant. I ended up getting surgery. My soccer
game has never been the same since.
Any previous medical, surgical, or dental I had my ACL repaired in my right knee. Nothing else.
procedures?
Are your immunizations up to date? I got all the childhood stuff. Nothing since.
Have you had the flu shot this year? No.
Have you had a colonoscopy? Nope
Are you taking any OTC or herbal Omeprazole OTC for my stomach. I get reflux
medications? sometimes after a spicy dinner, but I take that like the
box says and it takes care of the heartburn, no
