iHuman Anselmo Lopez Felipe Garcia Harvey Hoya Case High Blood pressure
57 y/o
5′ 9″ (175 cm)
195.0 lb (88.6 kg)
Reason for encounter
High blood pressure
Location
Outpatient clinic with x-ray, ECG, and laboratory capabilities
History Questions
- How can I help you today?
- What is your name?
- How would you like to be addressed?
- Is there anything I can do for you right now?
- Do you have any other symptoms or concerns we should discuss?
- How does this affect your life?
- Did you or have your ever lost consciousness?
- ……
Physical Exams Required
- Weight
- Height
- cognitive status
- SpO2
- temperature
- blood pressure
- pulse
- respiration
- …………….
Chief complaint: High blood pressure
Diagnosis: Hypertension primary (essential)
Anselmo Lopez, Felipe Garcia Case Problem Statement
Anselmo Lopez is a 57-year-old overweight Hispanic male construction worker and smoker who presents for evaluation of elevated blood-pressure reading of 170/92 noted at a recent local health fair. He takes ibuprofen for joint pain. He denies daytime somnolence and fatigue, interrupted sleep, snoring, apnea, chest pain, edema, or shortness of breath. Physical examination is notable for a BP of 172/94 on the left arm and 178/98 on the right arm, overweight BMI, fundoscopic findings of AV nicking and otherwise negative cardiopulmonary examination.
