NR509 Week 5 i-Human Case Study: Felipe Garcia
Complete SOAP Note & Treatment Plan
1. Patient Biodata & Reason for Encounter
Name: Felipe Garcia
, Age: 57 years old
Gender: Male
Ethnicity: Hispanic
Occupation: Factory Supervisor
Reason for Encounter: Follow-up evaluation requested due to an
elevated blood pressure screening (170/92 mmHg) at a local
health fair one week ago.
2. Case Introduction
Mr. Felipe Garcia is a 57-year-old male who presents for an outpatient
medical evaluation after a community screening revealed critically high
blood pressure. He has no prior established history of chronic
hypertension and does not routinely seek medical care. Upon
presentation, he is largely asymptomatic but acknowledges mild,
intermittent physiological complaints when questioned deeply. [1]
3. Chief Complaint
"I am here because they told me my blood pressure was too high at a
health fair last week."
4. Questions & Answers During Full i-Human History
, Q: Do you have a history of high blood pressure?
o A: "No, I haven't been to a doctor in years, so I didn't know it
was high until last week."
Q: Are you experiencing any headaches?
o A: "Sometimes I get a dull headache in the back of my head
when I wake up, but it usually goes away after a few hours."
Q: Any chest pain, shortness of breath, or heart palpitations?
o A: "No, nothing like that at all." [1]
Q: Do you experience any stomach discomfort?
o A: "Yes, I get a burning feeling in my upper stomach quite a bit,
especially after eating or when laying down."
Q: What medications do you take?
o A: "Just over-the-counter Ibuprofen. I take 400–600 mg a few
times a week for my knee osteoarthritis." [1]
Q: Do you smoke or drink alcohol?
o A: "I smoke about 1 pack of cigarettes a day and have a few
beers with friends on the weekends."
5. History
Complete SOAP Note & Treatment Plan
1. Patient Biodata & Reason for Encounter
Name: Felipe Garcia
, Age: 57 years old
Gender: Male
Ethnicity: Hispanic
Occupation: Factory Supervisor
Reason for Encounter: Follow-up evaluation requested due to an
elevated blood pressure screening (170/92 mmHg) at a local
health fair one week ago.
2. Case Introduction
Mr. Felipe Garcia is a 57-year-old male who presents for an outpatient
medical evaluation after a community screening revealed critically high
blood pressure. He has no prior established history of chronic
hypertension and does not routinely seek medical care. Upon
presentation, he is largely asymptomatic but acknowledges mild,
intermittent physiological complaints when questioned deeply. [1]
3. Chief Complaint
"I am here because they told me my blood pressure was too high at a
health fair last week."
4. Questions & Answers During Full i-Human History
, Q: Do you have a history of high blood pressure?
o A: "No, I haven't been to a doctor in years, so I didn't know it
was high until last week."
Q: Are you experiencing any headaches?
o A: "Sometimes I get a dull headache in the back of my head
when I wake up, but it usually goes away after a few hours."
Q: Any chest pain, shortness of breath, or heart palpitations?
o A: "No, nothing like that at all." [1]
Q: Do you experience any stomach discomfort?
o A: "Yes, I get a burning feeling in my upper stomach quite a bit,
especially after eating or when laying down."
Q: What medications do you take?
o A: "Just over-the-counter Ibuprofen. I take 400–600 mg a few
times a week for my knee osteoarthritis." [1]
Q: Do you smoke or drink alcohol?
o A: "I smoke about 1 pack of cigarettes a day and have a few
beers with friends on the weekends."
5. History
