CLINICAL CASE STUDY REPORT
Advanced Health Assessment & Management
CASE OVERVIEW
Week 7 — i-Human Patient Simulation
Patient: 56-Year-Old Hispanic Female
Chief Complaint: Blood Pressure Recheck
Setting: Outpatient Clinic with Laboratory Capabilities
Course: Class 6512 — Advanced Health Assessment
Academic Year: 2026
Prepared in Partial Fulfillment of Clinical Competency Requirements
i-Human Patient Simulation Platform
, History and Physical Examination
Initial Interview Questions
• How can I help you today?
• Do you have any other symptoms or concerns we can discuss?
• When did your high blood pressure start?
• How severe is your high blood pressure?
• Have you gained weight?
• When did your headache start?
Key Clinical Findings
Primary Findings
• Elevated blood pressure
• Headaches
• Daytime somnolence and fatigue
• Active smoker (approximately 1 pack per day since age 20s)
• Overweight status
• Hypertensive retinopathy — arteriovenous (A-V) nicking on funduscopic exam
• Laterally displaced point of maximal impulse (PMI)
• Snoring; partner reports observed apneic episodes during sleep
• NSAID use (ibuprofen for knee pain)
• Poor dietary habits (high sodium, high fat, fast food)
Clinical Problem Statement
The patient is a 56-year-old overweight Hispanic female construction worker who presents for
evaluation of an elevated blood pressure reading detected at a recent community health fair.
She reports intermittent mild headaches and interrupted sleep with snoring. Physical
examination is notable for BP 172/94 mmHg (left arm) and 178/98 mmHg (right arm), a laterally
displaced PMI, and funduscopic findings of arteriovenous nicking bilaterally. She was previously
informed of elevated blood pressure but took no action. Family history is positive for
hypertension and related cardiovascular complications.
Differential Diagnosis & Problem Analysis
The medical problem list compiled represents all findings that are outside normal parameters for
this patient. These findings were then examined and grouped according to their relationship to
the chief complaint — most significant active problem (MSAP) — and to recognized disease
Advanced Health Assessment & Management
CASE OVERVIEW
Week 7 — i-Human Patient Simulation
Patient: 56-Year-Old Hispanic Female
Chief Complaint: Blood Pressure Recheck
Setting: Outpatient Clinic with Laboratory Capabilities
Course: Class 6512 — Advanced Health Assessment
Academic Year: 2026
Prepared in Partial Fulfillment of Clinical Competency Requirements
i-Human Patient Simulation Platform
, History and Physical Examination
Initial Interview Questions
• How can I help you today?
• Do you have any other symptoms or concerns we can discuss?
• When did your high blood pressure start?
• How severe is your high blood pressure?
• Have you gained weight?
• When did your headache start?
Key Clinical Findings
Primary Findings
• Elevated blood pressure
• Headaches
• Daytime somnolence and fatigue
• Active smoker (approximately 1 pack per day since age 20s)
• Overweight status
• Hypertensive retinopathy — arteriovenous (A-V) nicking on funduscopic exam
• Laterally displaced point of maximal impulse (PMI)
• Snoring; partner reports observed apneic episodes during sleep
• NSAID use (ibuprofen for knee pain)
• Poor dietary habits (high sodium, high fat, fast food)
Clinical Problem Statement
The patient is a 56-year-old overweight Hispanic female construction worker who presents for
evaluation of an elevated blood pressure reading detected at a recent community health fair.
She reports intermittent mild headaches and interrupted sleep with snoring. Physical
examination is notable for BP 172/94 mmHg (left arm) and 178/98 mmHg (right arm), a laterally
displaced PMI, and funduscopic findings of arteriovenous nicking bilaterally. She was previously
informed of elevated blood pressure but took no action. Family history is positive for
hypertension and related cardiovascular complications.
Differential Diagnosis & Problem Analysis
The medical problem list compiled represents all findings that are outside normal parameters for
this patient. These findings were then examined and grouped according to their relationship to
the chief complaint — most significant active problem (MSAP) — and to recognized disease
