i-Human Week 4 Clinical Documentation: 56-Year-Old
Female Hypertension Follow-Up Case Study
Comprehensive Clinical Case Analysis with Detailed
Questions and Answers
,SECTION 1: PATIENT ENCOUNTER OVERVIEW
Case Identification
Element
Patient Name
Age/Gender SECTION 1: PATIENT ENCOUNTER OVERVIEW
Case Identification
,Element
Element Details
Patient Name Patricia "Patty" Marie Nelson
Age/Gender 56-year-old Caucasian female
Date of Birth March 15, 1970 (Age: 56 years)
MRN 884-21-5679
Date of Encounter Current visit (scheduled follow-up)
Encounter Type Outpatient primary care clinic visit
Provider Primary Care Physician (MD/DO/NP/PA)
Visit Duration 30 minutes scheduled
Reason for Visit Hypertension follow-up / blood pressure recheck
Chief Complaint (CC)
"My doctor asked me to come back today to check my blood pressure. It was high last week."
Patient's Own Words (Verbatim):
"I came in last Tuesday for my yearly physical and my blood pressure was really high - something like 15
over 94. The doctor told me to come back today to have it checked again. I've been trying to watch what
but I don't know if it's helping. I'm a little nervous about it actually."
SECTION 2: COMPREHENSIVE HISTORY OF PRESENTING ILLNESS
(HPI)
, Element
Detailed Chronological History
Background Context
Patricia Nelson is a 56-year-old female with a well-documented 5-year history of essential hypertension
Her initial diagnosis was made during a routine annual physical examination at age 51 when her blood
pressure was first noted to be 142/88 mmHg on two separate occasions. At that time, lifestyle
modifications were recommended, and she was started on lisinopril 10 mg daily. Over the subsequent
years, her blood pressure control has been suboptimal, with multiple clinic visits showing readings in th
140-150/85-95 mmHg range.
Index Visit (1 Week Ago)
Presenting Complaint at Index Visit: Routine annual physical examination and medication refill
Findings at Index Visit:
• Blood Pressure (first reading): 154/96 mmHg in right arm, seated
• Blood Pressure (second reading, 5 minutes later): 152/94 mmHg in left arm, seated
• Heart Rate: 80 bpm, regular
• Weight: 186.2 lbs (baseline from previous year: 182.0 lbs)
• BMI: 31.0 kg/m² (increased from 30.3 one year ago)
Action Taken at Index Visit:
• Patient instructed to return in 1 week for blood pressure recheck
• Encouraged to monitor blood pressure at home
• Reinforced importance of medication adherence
• Recommended dietary modifications
• Laboratory studies ordered: BMP, Lipid Panel, HbA1c, Urinalysis, TSH, ECG
Current Visit - History of Presenting Illness
Onset: The patient's hypertension was initially diagnosed 5 years ago; current issue relates to persisten
elevated readings identified 1 week ago.
Location: Systemic - blood pressure elevation, no localized symptoms reported
Female Hypertension Follow-Up Case Study
Comprehensive Clinical Case Analysis with Detailed
Questions and Answers
,SECTION 1: PATIENT ENCOUNTER OVERVIEW
Case Identification
Element
Patient Name
Age/Gender SECTION 1: PATIENT ENCOUNTER OVERVIEW
Case Identification
,Element
Element Details
Patient Name Patricia "Patty" Marie Nelson
Age/Gender 56-year-old Caucasian female
Date of Birth March 15, 1970 (Age: 56 years)
MRN 884-21-5679
Date of Encounter Current visit (scheduled follow-up)
Encounter Type Outpatient primary care clinic visit
Provider Primary Care Physician (MD/DO/NP/PA)
Visit Duration 30 minutes scheduled
Reason for Visit Hypertension follow-up / blood pressure recheck
Chief Complaint (CC)
"My doctor asked me to come back today to check my blood pressure. It was high last week."
Patient's Own Words (Verbatim):
"I came in last Tuesday for my yearly physical and my blood pressure was really high - something like 15
over 94. The doctor told me to come back today to have it checked again. I've been trying to watch what
but I don't know if it's helping. I'm a little nervous about it actually."
SECTION 2: COMPREHENSIVE HISTORY OF PRESENTING ILLNESS
(HPI)
, Element
Detailed Chronological History
Background Context
Patricia Nelson is a 56-year-old female with a well-documented 5-year history of essential hypertension
Her initial diagnosis was made during a routine annual physical examination at age 51 when her blood
pressure was first noted to be 142/88 mmHg on two separate occasions. At that time, lifestyle
modifications were recommended, and she was started on lisinopril 10 mg daily. Over the subsequent
years, her blood pressure control has been suboptimal, with multiple clinic visits showing readings in th
140-150/85-95 mmHg range.
Index Visit (1 Week Ago)
Presenting Complaint at Index Visit: Routine annual physical examination and medication refill
Findings at Index Visit:
• Blood Pressure (first reading): 154/96 mmHg in right arm, seated
• Blood Pressure (second reading, 5 minutes later): 152/94 mmHg in left arm, seated
• Heart Rate: 80 bpm, regular
• Weight: 186.2 lbs (baseline from previous year: 182.0 lbs)
• BMI: 31.0 kg/m² (increased from 30.3 one year ago)
Action Taken at Index Visit:
• Patient instructed to return in 1 week for blood pressure recheck
• Encouraged to monitor blood pressure at home
• Reinforced importance of medication adherence
• Recommended dietary modifications
• Laboratory studies ordered: BMP, Lipid Panel, HbA1c, Urinalysis, TSH, ECG
Current Visit - History of Presenting Illness
Onset: The patient's hypertension was initially diagnosed 5 years ago; current issue relates to persisten
elevated readings identified 1 week ago.
Location: Systemic - blood pressure elevation, no localized symptoms reported
