IHUMAN CASE STUDY. FELIPE
GARCIA 57-YEAR-OLD. REASON
FOR ENCOUNTER: HIGH BLOOD
PRESSURE.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Felipe Garcia
• Age: 57 years
• Gender: Male
• Marital Status: Married
• Occupation: Accountant
• Source of History: Patient (reliable historian)
Chief Complaint (CC)
"My blood pressure has been high even though I'm taking my medication."
History of Present Illness (HPI)
Felipe Garcia is a 57-year-old male who presents for evaluation of persistently
elevated blood pressure. He reports that over the past month, home blood
pressure readings have consistently ranged between 150–170 mmHg systolic
and 90–100 mmHg diastolic, despite taking his prescribed antihypertensive
medication. He became concerned after experiencing intermittent headaches
and occasional lightheadedness, prompting today's visit.
The headaches are dull, mild to moderate in intensity, and usually occur in the
back of the head. They are not associated with nausea, vomiting, blurred
vision, weakness, or loss of consciousness. He also reports occasional dizziness
when standing quickly but denies chest pain, palpitations, shortness of breath,
swelling of the legs, or fainting.
The patient admits that he sometimes forgets to take his medication,
particularly when busy at work. He also reports eating processed and salty
GARCIA 57-YEAR-OLD. REASON
FOR ENCOUNTER: HIGH BLOOD
PRESSURE.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Felipe Garcia
• Age: 57 years
• Gender: Male
• Marital Status: Married
• Occupation: Accountant
• Source of History: Patient (reliable historian)
Chief Complaint (CC)
"My blood pressure has been high even though I'm taking my medication."
History of Present Illness (HPI)
Felipe Garcia is a 57-year-old male who presents for evaluation of persistently
elevated blood pressure. He reports that over the past month, home blood
pressure readings have consistently ranged between 150–170 mmHg systolic
and 90–100 mmHg diastolic, despite taking his prescribed antihypertensive
medication. He became concerned after experiencing intermittent headaches
and occasional lightheadedness, prompting today's visit.
The headaches are dull, mild to moderate in intensity, and usually occur in the
back of the head. They are not associated with nausea, vomiting, blurred
vision, weakness, or loss of consciousness. He also reports occasional dizziness
when standing quickly but denies chest pain, palpitations, shortness of breath,
swelling of the legs, or fainting.
The patient admits that he sometimes forgets to take his medication,
particularly when busy at work. He also reports eating processed and salty
