[walden university]NR 509 WEEK 5 IHUMAN Case
Study: Felipe Garcia Complete With ALL Diagnosis,
SOAP Notes And Summerry
NR 509 WEEK 5 IHUMAN Case Study: Felipe Garcia Complete With SOAP Note
,Patient Name: Felipe Garcia
Age: 52
Gender: Male
Chief Complaint: "I've been feeling dizzy and have a headache for the
past few days."
RPI (History of Present Illness)
1: "Can you tell me more about your symptoms?"
Felipe Garcia: "Sure. I've had a headache for about three days now. It's
mostly in the back of my head, and it feels like pressure. I've also been
feeling dizzy, especially when I stand up quickly. I noticed my vision gets a
little blurry sometimes too."
2: "Have you checked your blood pressure recently?"
Felipe Garcia: "Yes, I checked it at the pharmacy two days ago, and it was
160/95. I was surprised because Ive never had high blood pressure before."
3: "Do you have any other symptoms, like chest pain, shortness of
breath, or nausea?"
Felipe Garcia: "No, none of that Just the headache and dizziness."
4: "Have you had any recent stress or changes in your life?"
Felipe Garcia: "Well, I've been under a lot of stress at work lately. I've
also been eating out more and not exercising as much as I should."
5: "Do you have a family history of high blood pressure or heart
disease?"
Felipe Garcia: "Yes, my father had high blood pressure, and he passed
away from a heart attack when he was 60."
6: "Do you smoke, drink alcohol, or use any recreational drugs?"
Felipe Garcia: "I don't smoke or use drugs, but I do drink a couple of
beers on the weekends."
7: "Are you taking any medications or supplements?"
Felipe Garcia: "No, I'm not taking anything right now."
, Past Medical History (PMH)
• No known history of hypertension, diabetes, or heart disease.
• No previous surgeries or hospitalizations.
Family History (FH)
• Father: Hypertension, died of myocardial infarction at age 60.
• Mother: Alive, has type 2 diabetes.
Social History (SH)
• Works as a manager at a manufacturing plant.
• Drinks alcohol socially (2-3 beers per week).
• Denies tobacco or illicit drug use.
• Sedentary lifestyle; reports minimal physical activity.
• Diet high in processed foods and sodium.
Study: Felipe Garcia Complete With ALL Diagnosis,
SOAP Notes And Summerry
NR 509 WEEK 5 IHUMAN Case Study: Felipe Garcia Complete With SOAP Note
,Patient Name: Felipe Garcia
Age: 52
Gender: Male
Chief Complaint: "I've been feeling dizzy and have a headache for the
past few days."
RPI (History of Present Illness)
1: "Can you tell me more about your symptoms?"
Felipe Garcia: "Sure. I've had a headache for about three days now. It's
mostly in the back of my head, and it feels like pressure. I've also been
feeling dizzy, especially when I stand up quickly. I noticed my vision gets a
little blurry sometimes too."
2: "Have you checked your blood pressure recently?"
Felipe Garcia: "Yes, I checked it at the pharmacy two days ago, and it was
160/95. I was surprised because Ive never had high blood pressure before."
3: "Do you have any other symptoms, like chest pain, shortness of
breath, or nausea?"
Felipe Garcia: "No, none of that Just the headache and dizziness."
4: "Have you had any recent stress or changes in your life?"
Felipe Garcia: "Well, I've been under a lot of stress at work lately. I've
also been eating out more and not exercising as much as I should."
5: "Do you have a family history of high blood pressure or heart
disease?"
Felipe Garcia: "Yes, my father had high blood pressure, and he passed
away from a heart attack when he was 60."
6: "Do you smoke, drink alcohol, or use any recreational drugs?"
Felipe Garcia: "I don't smoke or use drugs, but I do drink a couple of
beers on the weekends."
7: "Are you taking any medications or supplements?"
Felipe Garcia: "No, I'm not taking anything right now."
, Past Medical History (PMH)
• No known history of hypertension, diabetes, or heart disease.
• No previous surgeries or hospitalizations.
Family History (FH)
• Father: Hypertension, died of myocardial infarction at age 60.
• Mother: Alive, has type 2 diabetes.
Social History (SH)
• Works as a manager at a manufacturing plant.
• Drinks alcohol socially (2-3 beers per week).
• Denies tobacco or illicit drug use.
• Sedentary lifestyle; reports minimal physical activity.
• Diet high in processed foods and sodium.
