iHuman Patients-Anselmo Lopez
NR509 Week 5 iHuman
Case Study-Anselmo
Lopez
, iHuman Patients-Anselmo Lopez
NR509 Week 5 iHuman Case Study
Anselmo Lopez 57 y.o. M 5’9” 195.0 lbs. (88.6kg)
Reason for encounter: High Blood Pressure
**This case uses AHA/ACC guidelines. Please reference those as needed for evidence-
based case completion
Chief Complaint: Concern his blood pressure is high after attending a community health
fair.
Ask 2 open ended Questions: “How can I help you today?” “Any other symptoms or
concerns?”
History of Present Illness (HPI): A.L. is a 57-year-old male presenting for evaluation of
elevated blood pressure noted incidentally at a recent community health fair, where his
reading was reportedly 170/92 mmHg. He denies any associated symptoms such as
headache, chest pain, shortness of breath, palpitations, dizziness, or vision changes. He is
unsure how long his blood pressure has been elevated but recalls being told years ago by a
physician that his pressure was “a bit high” and that he should watch his diet. At the time,
he did not pursue further evaluation or treatment as he felt well. He does not currently
monitor his blood pressure and has not seen a regular healthcare provider until this visit.
He denies any known factors that exacerbate or alleviate his blood pressure and has not
received any previous treatment for hypertension.
He reports no current symptoms of concern and feels generally well. He does report a
history of right knee pain, which he attributes to a prior ACL injury and surgery following a
sports-related trauma. He uses OTC ibuprofen as needed (200 mg, 2–4 tablets, a couple of
times a day on a few days per week), which he reports helps relieve his knee pain. He also
takes OTC omeprazole as directed for occasional heartburn, especially after spicy meals.
He denies any chest pain, dyspnea, palpitations, or malaise.
His past medical history is otherwise unremarkable aside from episodic gastritis/acid
reflux and chronic right knee discomfort. He denies having a primary care provider and this
is his first medical evaluation in several years.
Family history is significant for hypertension in his brother and uncle, diabetes in his
mother and maternal grandmother, and cardiovascular disease with premature death on
, iHuman Patients-Anselmo Lopez
the paternal side — his father died of a stroke at age 62 and his paternal grandfather of a
heart attack at age 52.
NR509 Week 5 iHuman
Case Study-Anselmo
Lopez
, iHuman Patients-Anselmo Lopez
NR509 Week 5 iHuman Case Study
Anselmo Lopez 57 y.o. M 5’9” 195.0 lbs. (88.6kg)
Reason for encounter: High Blood Pressure
**This case uses AHA/ACC guidelines. Please reference those as needed for evidence-
based case completion
Chief Complaint: Concern his blood pressure is high after attending a community health
fair.
Ask 2 open ended Questions: “How can I help you today?” “Any other symptoms or
concerns?”
History of Present Illness (HPI): A.L. is a 57-year-old male presenting for evaluation of
elevated blood pressure noted incidentally at a recent community health fair, where his
reading was reportedly 170/92 mmHg. He denies any associated symptoms such as
headache, chest pain, shortness of breath, palpitations, dizziness, or vision changes. He is
unsure how long his blood pressure has been elevated but recalls being told years ago by a
physician that his pressure was “a bit high” and that he should watch his diet. At the time,
he did not pursue further evaluation or treatment as he felt well. He does not currently
monitor his blood pressure and has not seen a regular healthcare provider until this visit.
He denies any known factors that exacerbate or alleviate his blood pressure and has not
received any previous treatment for hypertension.
He reports no current symptoms of concern and feels generally well. He does report a
history of right knee pain, which he attributes to a prior ACL injury and surgery following a
sports-related trauma. He uses OTC ibuprofen as needed (200 mg, 2–4 tablets, a couple of
times a day on a few days per week), which he reports helps relieve his knee pain. He also
takes OTC omeprazole as directed for occasional heartburn, especially after spicy meals.
He denies any chest pain, dyspnea, palpitations, or malaise.
His past medical history is otherwise unremarkable aside from episodic gastritis/acid
reflux and chronic right knee discomfort. He denies having a primary care provider and this
is his first medical evaluation in several years.
Family history is significant for hypertension in his brother and uncle, diabetes in his
mother and maternal grandmother, and cardiovascular disease with premature death on
, iHuman Patients-Anselmo Lopez
the paternal side — his father died of a stroke at age 62 and his paternal grandfather of a
heart attack at age 52.
