56-Year-Old Male with Blood Pressure Recheck
(CLASS 6512) LOCATION; OUTPATIENT CLINIC
WITH BP MONITORING, ECG, AND LABORATORY
CAPABILITIES | iHuman Case Week #7 56-Year-
Old Male Reason for Encounter: Blood Pressure
Recheck (CLASS 6512) LOCATION; OUTPATIENT
Patient Introduction:
This is a 56-year-old female with a 2-year history of hypertension, presenting with persistently
elevated blood pressure. She reports intermittent occipital headaches for the past three weeks,
, sometimes accompanied by mild dizziness and blurred vision. She has been irregular in taking
her antihypertensive medication and has not attended regular follow-up visits. No history of
diabetes, kidney disease, or cardiovascular events. Family history is notable for maternal
hypertension and stroke, and paternal type 2 diabetes.
History of Present Illness (HPI):
The patient is a 56-year-old female with a known history of hypertension for the past two years,
presenting for evaluation of persistently elevated blood pressure. She reports intermittent
occipital headaches over the last three weeks, occasionally associated with mild dizziness and
blurred vision. She denies chest pain, palpitations, shortness of breath, syncope, swelling of the
legs, or weakness. She admits to inconsistent use of her prescribed antihypertensive medication
due to forgetfulness and has missed recent follow-up appointments. There has been no recent
illness, major dietary changes, or increase in salt intake. She denies any history of kidney
sease, diabetes mellitus, or prior stroke
Past Medical History (PMH):
• Hypertension – diagnosed 2 years ago; currently on irregular treatment.
• No history of diabetes mellitus, chronic kidney disease, cardiovascular disease, or stroke.
• No past hospitalizations or major surgeries.
• No known drug or food allergies.
Family History:
• Mother had hypertension and died from a stroke at age 72.
• Father had type 2 diabetes mellitus.
• No known family history of kidney disease or premature heart disease.
Social History:
• Married, lives with spouse.
• Works as a shopkeeper.
• Denies smoking and alcohol consumption.
• Diet: moderate salt intake, low fruit and vegetable consumption.
• Sedentary lifestyle with minimal regular physical activity.
• No history of illicit drug use.
Review of Systems (ROS):
• General: No fever, chills, night sweats, or unintentional weight change.
• HEENT/Eyes: Intermittent occipital headaches for ~3 weeks; occasional blurred vision.
No ear pain, nasal congestion, sore throat, or nosebleeds.
• Cardiovascular: No chest pain, palpitations, shortness of breath when lying flat, or leg
swelling.
• Respiratory: No cough, wheezing, or shortness of breath on exertion.
(CLASS 6512) LOCATION; OUTPATIENT CLINIC
WITH BP MONITORING, ECG, AND LABORATORY
CAPABILITIES | iHuman Case Week #7 56-Year-
Old Male Reason for Encounter: Blood Pressure
Recheck (CLASS 6512) LOCATION; OUTPATIENT
Patient Introduction:
This is a 56-year-old female with a 2-year history of hypertension, presenting with persistently
elevated blood pressure. She reports intermittent occipital headaches for the past three weeks,
, sometimes accompanied by mild dizziness and blurred vision. She has been irregular in taking
her antihypertensive medication and has not attended regular follow-up visits. No history of
diabetes, kidney disease, or cardiovascular events. Family history is notable for maternal
hypertension and stroke, and paternal type 2 diabetes.
History of Present Illness (HPI):
The patient is a 56-year-old female with a known history of hypertension for the past two years,
presenting for evaluation of persistently elevated blood pressure. She reports intermittent
occipital headaches over the last three weeks, occasionally associated with mild dizziness and
blurred vision. She denies chest pain, palpitations, shortness of breath, syncope, swelling of the
legs, or weakness. She admits to inconsistent use of her prescribed antihypertensive medication
due to forgetfulness and has missed recent follow-up appointments. There has been no recent
illness, major dietary changes, or increase in salt intake. She denies any history of kidney
sease, diabetes mellitus, or prior stroke
Past Medical History (PMH):
• Hypertension – diagnosed 2 years ago; currently on irregular treatment.
• No history of diabetes mellitus, chronic kidney disease, cardiovascular disease, or stroke.
• No past hospitalizations or major surgeries.
• No known drug or food allergies.
Family History:
• Mother had hypertension and died from a stroke at age 72.
• Father had type 2 diabetes mellitus.
• No known family history of kidney disease or premature heart disease.
Social History:
• Married, lives with spouse.
• Works as a shopkeeper.
• Denies smoking and alcohol consumption.
• Diet: moderate salt intake, low fruit and vegetable consumption.
• Sedentary lifestyle with minimal regular physical activity.
• No history of illicit drug use.
Review of Systems (ROS):
• General: No fever, chills, night sweats, or unintentional weight change.
• HEENT/Eyes: Intermittent occipital headaches for ~3 weeks; occasional blurred vision.
No ear pain, nasal congestion, sore throat, or nosebleeds.
• Cardiovascular: No chest pain, palpitations, shortness of breath when lying flat, or leg
swelling.
• Respiratory: No cough, wheezing, or shortness of breath on exertion.
