i-Human Week 4 Clinical Documentation: 56-Year-Old Female Hypertension Follow-Up Case Study by i-Human Patients Academic Team – Latest 2025/2026 Guide to Pass Exams on First Attempt

,**Patient:** Patricia "Patty" Nelson, 56-year-old Caucasian female
**Reason for Encounter:** Blood pressure recheck
**Chief Complaint:** "My doctor asked me to come back today to
check my blood pressure. It was high last week."
**Setting:** Outpatient primary care clinic with laboratory
capabilities


**Vital Statistics:**
- Height: 5'5" (165 cm)
- Weight: 188.0 lb (85.5 kg)
- BMI: 31.2-31.3 kg/m² (Class I Obesity)
- Waist Circumference: 92 cm (elevated; ≥88 cm indicates abdominal
obesity)


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## History of Present Illness (HPI)


Patricia Nelson is a 56-year-old female with a 5-year history of
hypertension presenting for a scheduled blood pressure recheck.
One week ago, during a routine health maintenance visit, her blood
pressure was noted to be 152/94 mmHg (taken twice, 5 minutes
apart). She was advised to return today for repeat measurement and
further evaluation .

, **Medication Adherence:** Reports taking antihypertensive
medication intermittently, missing doses due to forgetfulness and
work commitments


**Home BP Monitoring:** Occasional; readings elevated (~150/90
mmHg range)


**Associated Symptoms - All Denied:**
- Headaches
- Dizziness
- Vision changes
- Chest pain
- Palpitations
- Shortness of breath
- Fatigue
- Lower extremity swelling


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## Past Medical History (PMH)


**Active Conditions:**
- Hypertension (diagnosed 5 years ago)
- No known diabetes mellitus