NR509 Week 5 i-Human Case Study: Felipe Garcia | Complete
Comprehensive SOAP Note, Differential Diagnosis Matrix & Clinical
Management Plan 2026 Edition | INSTANT PDF DOWNLOAD
1. Patient Biodata & Reason for Encounter
, Name: Felipe Garcia
Age/Gender: 57 years old / Male
Race/Ethnicity: Hispanic / Latino
Occupation: Full-time Construction Foreman (High physical labor,
high stress)
Marital Status: Married
Source of History: Patient (Reliable) and spouse (collateral sleep
history)
Reason for Encounter: Evaluation of elevated blood pressure
readings found during a work health screening, accompanied by
morning headaches and episodic lightheadedness.
2. Case Introduction
Felipe Garcia is a 57-year-old male construction worker with no
established primary care provider who presents with uncontrolled Stage
2 Hypertension discovered during a workplace screening (\(168/94
\text{ mmHg}\)). Over the past 3 to 4 months, he has developed a
pattern of dull, tight, morning headaches and brief orthostatic
lightheadedness. He concurrently describes a 6-month history of
retrosternal burning (heartburn). His wife reports loud snoring and
gasping episodes during sleep. He maintains a high-sodium fast-food diet
and relies heavily on daily over-the-counter (OTC) Ibuprofen for
musculoskeletal aches and headaches, compromising his vascular
, hemodynamics. He has a strong paternal family history of premature
cardiovascular events.
3. Chief Complaint (CC)
"I'm here to check out my high blood pressure from a work health fair.
I've also been getting bad headaches in the morning and feeling dizzy
when I move too fast."
4. Questions and Answers During Full History
1. How can I help you today? "My company had a health fair last
week and they told me my blood pressure was dangerously high
(\(168/94\)). I also have these nagging morning headaches and feel
a bit dizzy sometimes."
2. When did your headaches start and how often do they occur?
"They started about 3 to 4 months ago. Now I get them almost every
single morning when I wake up. They usually fade by lunchtime."
3. Can you describe the pain of your headaches? "It feels like a
dull, tight, heavy ache all over my head. It's not throbbing on one
side like a migraine, just a constant tight band."
4. What makes the headaches better or worse? "Taking Ibuprofen
or Tylenol helps a little bit. It gets worse if I have a stressful day on
the construction yard or if I don't sleep well."
5. Tell me more about the dizziness you feel. "It’s not like the room
is spinning. It’s a brief lightheaded feeling that happens when I jump
Comprehensive SOAP Note, Differential Diagnosis Matrix & Clinical
Management Plan 2026 Edition | INSTANT PDF DOWNLOAD
1. Patient Biodata & Reason for Encounter
, Name: Felipe Garcia
Age/Gender: 57 years old / Male
Race/Ethnicity: Hispanic / Latino
Occupation: Full-time Construction Foreman (High physical labor,
high stress)
Marital Status: Married
Source of History: Patient (Reliable) and spouse (collateral sleep
history)
Reason for Encounter: Evaluation of elevated blood pressure
readings found during a work health screening, accompanied by
morning headaches and episodic lightheadedness.
2. Case Introduction
Felipe Garcia is a 57-year-old male construction worker with no
established primary care provider who presents with uncontrolled Stage
2 Hypertension discovered during a workplace screening (\(168/94
\text{ mmHg}\)). Over the past 3 to 4 months, he has developed a
pattern of dull, tight, morning headaches and brief orthostatic
lightheadedness. He concurrently describes a 6-month history of
retrosternal burning (heartburn). His wife reports loud snoring and
gasping episodes during sleep. He maintains a high-sodium fast-food diet
and relies heavily on daily over-the-counter (OTC) Ibuprofen for
musculoskeletal aches and headaches, compromising his vascular
, hemodynamics. He has a strong paternal family history of premature
cardiovascular events.
3. Chief Complaint (CC)
"I'm here to check out my high blood pressure from a work health fair.
I've also been getting bad headaches in the morning and feeling dizzy
when I move too fast."
4. Questions and Answers During Full History
1. How can I help you today? "My company had a health fair last
week and they told me my blood pressure was dangerously high
(\(168/94\)). I also have these nagging morning headaches and feel
a bit dizzy sometimes."
2. When did your headaches start and how often do they occur?
"They started about 3 to 4 months ago. Now I get them almost every
single morning when I wake up. They usually fade by lunchtime."
3. Can you describe the pain of your headaches? "It feels like a
dull, tight, heavy ache all over my head. It's not throbbing on one
side like a migraine, just a constant tight band."
4. What makes the headaches better or worse? "Taking Ibuprofen
or Tylenol helps a little bit. It gets worse if I have a stressful day on
the construction yard or if I don't sleep well."
5. Tell me more about the dizziness you feel. "It’s not like the room
is spinning. It’s a brief lightheaded feeling that happens when I jump
