Shadow Health - Xavier Daniels: New
Patient Visit Treatment Plan Guide
(2025-2026)
1. PATIENT INTERVIEW / SUBJECTIVE FINDINGS
Chief Complaint
● "I’ve been feeling really tired lately, and my blood pressure has been high."
○ Rationale: Xavier’s primary concern aligns with fatigue and hypertension
(HTN), which are interconnected due to lifestyle factors (obesity, stress, poor
diet).
History of Present Illness (HPI)
Component Xavier’s Responses Clinical Significance
Onset "A few months ago, but Chronic fatigue suggests lifestyle-related
it’s gotten worse." HTN or sleep apnea.
Location "All over, but mostly my Head heaviness may indicate HTN
head feels heavy." headaches or stress-related tension.
Duration "Constant for weeks." Persistent symptoms warrant HTN
evaluation and lifestyle assessment.
Characteristics "Dull, like I’m dragging." Non-specific but consistent with fatigue from
poor sleep, HTN, or depression.
Aggravating "Stress at work and Diet (high sodium) and stress are HTN risk
Factors eating fast food." factors.
Relieving "Rest helps a little, but Inadequate relief suggests underlying
Factors not much." chronic condition (HTN, obesity, sleep
apnea).
, Treatments Tried "None, just Lack of HTN management indicates need for
over-the-counter pain education and intervention.
relievers."
Medication Review
● Current Medications: None.
● OTC Use: Ibuprofen for headaches (2–3x/week).
○ Rationale: NSAID use may mask HTN symptoms and increase renal risk in
uncontrolled HTN.
Allergies
● NKDA (No Known Drug Allergies).
● Environmental: Dust mites (mild rhinitis).
Past Medical History (PMH)
● HTN: New diagnosis (BP 158/96 at last visit).
● Obesity: BMI 32.1 (Class I obesity).
● Prediabetes: HbA1c 5.9% (2023).
● GERD: Occasional heartburn (managed with OTC antacids).
● No surgeries or hospitalizations.
Family History
● Father: HTN, Type 2 DM, MI at age 55.
● Mother: Obesity, hyperlipidemia.
● Siblings: One brother with HTN.
○ Rationale: Strong genetic risk for HTN, DM, and CVD.
Social History
Factor Xavier’s Responses Clinical Implications
Tobacc "I quit 2 years ago (1 ppd x Former smoker → CVD risk remains elevated
o 10 years)." for 10+ years post-cessation.
Alcohol "2–3 beers on weekends." Moderate use (within guidelines), but HTN risk if
combined with high sodium.
Drugs Denies illicit drug use. Low risk, but screen for stress-related substance
use .
Patient Visit Treatment Plan Guide
(2025-2026)
1. PATIENT INTERVIEW / SUBJECTIVE FINDINGS
Chief Complaint
● "I’ve been feeling really tired lately, and my blood pressure has been high."
○ Rationale: Xavier’s primary concern aligns with fatigue and hypertension
(HTN), which are interconnected due to lifestyle factors (obesity, stress, poor
diet).
History of Present Illness (HPI)
Component Xavier’s Responses Clinical Significance
Onset "A few months ago, but Chronic fatigue suggests lifestyle-related
it’s gotten worse." HTN or sleep apnea.
Location "All over, but mostly my Head heaviness may indicate HTN
head feels heavy." headaches or stress-related tension.
Duration "Constant for weeks." Persistent symptoms warrant HTN
evaluation and lifestyle assessment.
Characteristics "Dull, like I’m dragging." Non-specific but consistent with fatigue from
poor sleep, HTN, or depression.
Aggravating "Stress at work and Diet (high sodium) and stress are HTN risk
Factors eating fast food." factors.
Relieving "Rest helps a little, but Inadequate relief suggests underlying
Factors not much." chronic condition (HTN, obesity, sleep
apnea).
, Treatments Tried "None, just Lack of HTN management indicates need for
over-the-counter pain education and intervention.
relievers."
Medication Review
● Current Medications: None.
● OTC Use: Ibuprofen for headaches (2–3x/week).
○ Rationale: NSAID use may mask HTN symptoms and increase renal risk in
uncontrolled HTN.
Allergies
● NKDA (No Known Drug Allergies).
● Environmental: Dust mites (mild rhinitis).
Past Medical History (PMH)
● HTN: New diagnosis (BP 158/96 at last visit).
● Obesity: BMI 32.1 (Class I obesity).
● Prediabetes: HbA1c 5.9% (2023).
● GERD: Occasional heartburn (managed with OTC antacids).
● No surgeries or hospitalizations.
Family History
● Father: HTN, Type 2 DM, MI at age 55.
● Mother: Obesity, hyperlipidemia.
● Siblings: One brother with HTN.
○ Rationale: Strong genetic risk for HTN, DM, and CVD.
Social History
Factor Xavier’s Responses Clinical Implications
Tobacc "I quit 2 years ago (1 ppd x Former smoker → CVD risk remains elevated
o 10 years)." for 10+ years post-cessation.
Alcohol "2–3 beers on weekends." Moderate use (within guidelines), but HTN risk if
combined with high sodium.
Drugs Denies illicit drug use. Low risk, but screen for stress-related substance
use .
