Actual Comprehensive i-Human Case Study Week
#7 | 56 y/o 5' 5"' (165 cm) 188.0 lb (85.5 kg) |
Reason for Encounter: Blood Pressure
Recheck(class 6531) | Location Outpatient clinic
with laboratory capabilities.
Patient Introduction:
This is a 56-year-old female who presents with a history of elevated blood pressure. She reports
recent episodes of headache and occasional dizziness. She has no prior history of cardiovascular
events but was diagnosed with hypertension during a routine checkup two years ago and has
been on irregular follow-up since.
, 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
headaches, particularly in the occipital region, over the past three weeks, sometimes
accompanied by mild dizziness and blurred vision. She denies chest pain, palpitations, shortness
of breath, syncope, or swelling of the legs. She admits to inconsistent use of her antihypertensive
medication due to forgetfulness and lack of regular follow-up. There is no history of recent
illness, excessive salt intake, or changes in physical activity. No history of kidney disease,
diabetes, or stroke.
Past Medical History:
• Hypertension – diagnosed 2 years ago, currently on irregular treatment.
• No history of diabetes mellitus, chronic kidney disease, cardiovascular disease, or stroke.
• No known history of hyperlipidemia.
• No past hospitalizations or major surgeries.
• No history of allergies to medications or foods.
Family History:
• Mother had hypertension and passed away 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 tobacco smoking or alcohol consumption.
• Diet includes moderate salt intake; limited consumption of fruits and vegetables.
• Sedentary lifestyle with minimal regular exercise.
• No history of illicit drug use.
Review of Systems (ROS)
• General: Denies fever, chills, night sweats, or unintentional weight change.
• HEENT / Eyes: Positive for intermittent occipital headaches (≈3 weeks) and intermittent
blurred vision. Denies ear pain, nasal congestion, sore throat, or epistaxis.
• Cardiovascular: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal
dyspnea, or peripheral edema.
• Respiratory: Denies cough, wheeze, or shortness of breath on exertion.
• Gastrointestinal: Denies nausea, vomiting, abdominal pain, diarrhea, or change in bowel
habits.
• Genitourinary: Denies dysuria, hematuria, urinary frequency/urgency, or nocturia.
#7 | 56 y/o 5' 5"' (165 cm) 188.0 lb (85.5 kg) |
Reason for Encounter: Blood Pressure
Recheck(class 6531) | Location Outpatient clinic
with laboratory capabilities.
Patient Introduction:
This is a 56-year-old female who presents with a history of elevated blood pressure. She reports
recent episodes of headache and occasional dizziness. She has no prior history of cardiovascular
events but was diagnosed with hypertension during a routine checkup two years ago and has
been on irregular follow-up since.
, 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
headaches, particularly in the occipital region, over the past three weeks, sometimes
accompanied by mild dizziness and blurred vision. She denies chest pain, palpitations, shortness
of breath, syncope, or swelling of the legs. She admits to inconsistent use of her antihypertensive
medication due to forgetfulness and lack of regular follow-up. There is no history of recent
illness, excessive salt intake, or changes in physical activity. No history of kidney disease,
diabetes, or stroke.
Past Medical History:
• Hypertension – diagnosed 2 years ago, currently on irregular treatment.
• No history of diabetes mellitus, chronic kidney disease, cardiovascular disease, or stroke.
• No known history of hyperlipidemia.
• No past hospitalizations or major surgeries.
• No history of allergies to medications or foods.
Family History:
• Mother had hypertension and passed away 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 tobacco smoking or alcohol consumption.
• Diet includes moderate salt intake; limited consumption of fruits and vegetables.
• Sedentary lifestyle with minimal regular exercise.
• No history of illicit drug use.
Review of Systems (ROS)
• General: Denies fever, chills, night sweats, or unintentional weight change.
• HEENT / Eyes: Positive for intermittent occipital headaches (≈3 weeks) and intermittent
blurred vision. Denies ear pain, nasal congestion, sore throat, or epistaxis.
• Cardiovascular: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal
dyspnea, or peripheral edema.
• Respiratory: Denies cough, wheeze, or shortness of breath on exertion.
• Gastrointestinal: Denies nausea, vomiting, abdominal pain, diarrhea, or change in bowel
habits.
• Genitourinary: Denies dysuria, hematuria, urinary frequency/urgency, or nocturia.
