comprehensive i-Human Week 4 clinical case file
detailing a 56-year-old female patient's visit for a blood
pressure recheck and hypertension follow-up in an
outpatient clinic. This essential resource is updated for
the 2025/2026 academic year
,SECTION 1: CASE OVERVIEW AND PATIENT
DEMOGRAPHICS
Patient Identification
Demographic Detail
Name Patricia "Patty" Nelson
,Demographic Detail
Age 56 years old
Sex Female
Race/Ethnicity Caucasian
Date of Birth Calculated from age (approximately 1970)
Height 5'5" (165 cm)
Weight 188.0 lb (85.5 kg)
BMI 31.3 kg/m² (Class I Obesity)
Waist Circumference 92 cm (36.2 inches) – elevated (≥88 cm indicates abdominal obesity)
Encounter Information
Setting Detail
Type Outpatient Primary Care Clinic
Reason for
Blood Pressure Recheck
Encounter
"My doctor asked me to come back today to check my blood pressure. It was hig
Chief Complaint
last week."
Date of Visit Current date
Referring Provider Primary Care Physician (established)
Vital Statistics Summary
, Parameter Value Interpretation
Sitting BP (R arm, 5 min rest) 148/90 mmHg Stage 2 Hypertension
Repeat BP (R arm, 5 min later) 146/92 mmHg Stage 2 Hypertension
Sitting BP (L arm) 150/88 mmHg Stage 2 Hypertension
Average BP ~147/90 mmHg Stage 2 Hypertension
Heart Rate 78-84 bpm, regular Normal
Respiratory Rate 16-18 breaths/min Normal
Temperature 98.4°F (36.9°C) Normal
Oxygen Saturation 98-99% on room air Normal
BMI 31.3 kg/m² Obese Class I
SECTION 2: SUBJECTIVE DATA (HISTORY OF PRESENT
ILLNESS)
Chief Complaint (CC)
"My doctor asked me to come back today to check my blood pressure. It was high last
week."
History of Present Illness (HPI)
Patricia Nelson is a 56-year-old Caucasian female with a 5-year history of hypertension
presenting for a scheduled blood pressure recheck in the outpatient primary care setting.
One week ago, during a routine health maintenance visit, her blood pressure was noted
to be 152/94 mmHg, measured twice at 5-minute intervals. She was advised to return
today for repeat measurement and further evaluation of her blood pressure control.
detailing a 56-year-old female patient's visit for a blood
pressure recheck and hypertension follow-up in an
outpatient clinic. This essential resource is updated for
the 2025/2026 academic year
,SECTION 1: CASE OVERVIEW AND PATIENT
DEMOGRAPHICS
Patient Identification
Demographic Detail
Name Patricia "Patty" Nelson
,Demographic Detail
Age 56 years old
Sex Female
Race/Ethnicity Caucasian
Date of Birth Calculated from age (approximately 1970)
Height 5'5" (165 cm)
Weight 188.0 lb (85.5 kg)
BMI 31.3 kg/m² (Class I Obesity)
Waist Circumference 92 cm (36.2 inches) – elevated (≥88 cm indicates abdominal obesity)
Encounter Information
Setting Detail
Type Outpatient Primary Care Clinic
Reason for
Blood Pressure Recheck
Encounter
"My doctor asked me to come back today to check my blood pressure. It was hig
Chief Complaint
last week."
Date of Visit Current date
Referring Provider Primary Care Physician (established)
Vital Statistics Summary
, Parameter Value Interpretation
Sitting BP (R arm, 5 min rest) 148/90 mmHg Stage 2 Hypertension
Repeat BP (R arm, 5 min later) 146/92 mmHg Stage 2 Hypertension
Sitting BP (L arm) 150/88 mmHg Stage 2 Hypertension
Average BP ~147/90 mmHg Stage 2 Hypertension
Heart Rate 78-84 bpm, regular Normal
Respiratory Rate 16-18 breaths/min Normal
Temperature 98.4°F (36.9°C) Normal
Oxygen Saturation 98-99% on room air Normal
BMI 31.3 kg/m² Obese Class I
SECTION 2: SUBJECTIVE DATA (HISTORY OF PRESENT
ILLNESS)
Chief Complaint (CC)
"My doctor asked me to come back today to check my blood pressure. It was high last
week."
History of Present Illness (HPI)
Patricia Nelson is a 56-year-old Caucasian female with a 5-year history of hypertension
presenting for a scheduled blood pressure recheck in the outpatient primary care setting.
One week ago, during a routine health maintenance visit, her blood pressure was noted
to be 152/94 mmHg, measured twice at 5-minute intervals. She was advised to return
today for repeat measurement and further evaluation of her blood pressure control.
