Chamberlain University
NR 509 / NR509
Week 5 iHuman Case
Study
Case: Evaluation of Hypertension in a 57-
Year-Old Male
,Anselmo Lopez
57 years old
Reason for encounter- high blood pressure
Location- outpatient clinic with x-ray, ECG, and laboratory capabilities
General: well-groomed, tired appearing and dressed in gown
Skin: warm, nondiaphoretic
Questions
1. How can I help you today? Recently at health fair—nurse told him to see
doctor—BP 170/92---wife was concerned and made appointment.
2. Someone told him that he had gastritis
3. Have achy knees
4. Don’t see doctor on regular basis
5. Cup of coffee in the morning—eat fast food for lunch and texmex for dinner---chips
HPI
o Reason for encounter- high blood pressure noted at a health fair
o History of present illness
AL is 57-year-old Hispanic male who present to the clinic for evaluation of high
blood pressure, first noted at a health fair with reading of 170/92. His wife was
concerned and scheduled this appointment. The patient denies any prior history of
hypertension and does not see a doctor regularly. He has no known history of
cardiovascular disease but reports family history of hypertension, stroke, and heart
attack. He takes OTC Omeprazole for heartburn and stomach pain (2/10) and OTC
Ibuprofen for chronic bilateral knee pain (3- 4/10) which helps him with symptoms.
Spicy food makes his stomach pain worst. His lifestyle includes a diet high in
processed and fast foods, minimal exercise (only walking his dog), smoking 1 pack per
day since his 20s, and weekend alcohol consumption. He works in construction doing
flooring installation and cabinetry. He denies chest pain, shortness of breath,
palpitations, dizziness, headache, vision changes, swelling in extremities, excessive
thirst or urination, stress, or depression.
o Review of systems
1. General- denies recent unintentional weight loss but has gained a few punds
over the years and has “big belly”. Denies weakness, fatigue or fever.
2. HEENT/neck
Downloaded by Benjamin Luca ()
, Head- denies headache or dizziness
Eyes- Wears drugstore glasses for reading, denies double vision. Flashing
lights Ears- denies hearing difficulty
Norse- denies nosebleeds, nasal stuffiness, or discharge
Downloaded by Benjamin Luca ()
NR 509 / NR509
Week 5 iHuman Case
Study
Case: Evaluation of Hypertension in a 57-
Year-Old Male
,Anselmo Lopez
57 years old
Reason for encounter- high blood pressure
Location- outpatient clinic with x-ray, ECG, and laboratory capabilities
General: well-groomed, tired appearing and dressed in gown
Skin: warm, nondiaphoretic
Questions
1. How can I help you today? Recently at health fair—nurse told him to see
doctor—BP 170/92---wife was concerned and made appointment.
2. Someone told him that he had gastritis
3. Have achy knees
4. Don’t see doctor on regular basis
5. Cup of coffee in the morning—eat fast food for lunch and texmex for dinner---chips
HPI
o Reason for encounter- high blood pressure noted at a health fair
o History of present illness
AL is 57-year-old Hispanic male who present to the clinic for evaluation of high
blood pressure, first noted at a health fair with reading of 170/92. His wife was
concerned and scheduled this appointment. The patient denies any prior history of
hypertension and does not see a doctor regularly. He has no known history of
cardiovascular disease but reports family history of hypertension, stroke, and heart
attack. He takes OTC Omeprazole for heartburn and stomach pain (2/10) and OTC
Ibuprofen for chronic bilateral knee pain (3- 4/10) which helps him with symptoms.
Spicy food makes his stomach pain worst. His lifestyle includes a diet high in
processed and fast foods, minimal exercise (only walking his dog), smoking 1 pack per
day since his 20s, and weekend alcohol consumption. He works in construction doing
flooring installation and cabinetry. He denies chest pain, shortness of breath,
palpitations, dizziness, headache, vision changes, swelling in extremities, excessive
thirst or urination, stress, or depression.
o Review of systems
1. General- denies recent unintentional weight loss but has gained a few punds
over the years and has “big belly”. Denies weakness, fatigue or fever.
2. HEENT/neck
Downloaded by Benjamin Luca ()
, Head- denies headache or dizziness
Eyes- Wears drugstore glasses for reading, denies double vision. Flashing
lights Ears- denies hearing difficulty
Norse- denies nosebleeds, nasal stuffiness, or discharge
Downloaded by Benjamin Luca ()
