I Human Case Week #7 56 Year Old Female
Reason For Encounter: Blood Pressure Recheck
Class 6512
,
,🧠 4. Assessment
Primary Diagnosis:
Hypertension, Stage 1–2 (I10)
o Patient is showing improved but still elevated BP.
o Likely essential hypertension, no signs of secondary causes.
o Responding to initial Lisinopril therapy, but not yet at target
(<130/80).
Comorbidities:
Hyperlipidemia
Obesity
🔍 5. Differential Diagnoses
1. Essential Hypertension – most likely; confirmed by prior reading
and current patterns.
2. Secondary Hypertension (e.g., renal, endocrine) – less likely, no
red flags.
3. White Coat Hypertension – possible contributor; home readings
are better.
4. Medication Nonadherence – unlikely, patient reports compliance.
5. Masked Hypertension – opposite of white coat, less likely here.
📋6
Past Medical History (PMH):
, Hypertension (diagnosed 2 weeks ago)
Hyperlipidemia (diagnosed 2 years ago)
Obesity (BMI ~32)
No history of diabetes
No known cardiovascular disease
Past Surgical History (PSH):
Appendectomy in her 20s
Tubal ligation in her 30s
. Plan (SOAP “P”)
Medications:
Continue Lisinopril 10 mg daily
Consider titration to 20 mg daily if BP remains above goal in 2–4
weeks
Monitor electrolytes and renal function (BMP/CMP) 1–2 weeks
after any med change
Lifestyle Modifications:
Continue DASH diet: low sodium, rich in fruits/vegetables
Encourage weight loss (target 5–10% reduction)
Physical activity: At least 150 minutes of moderate-intensity
aerobic exercise/week
Limit alcohol (≤1 drink/day for women)
Monitoring:
Home BP log: check 2x/day, log readings
Recheck in 2–4 weeks
Watch for cough, dizziness (possible Lisinopril side effects)
Reason For Encounter: Blood Pressure Recheck
Class 6512
,
,🧠 4. Assessment
Primary Diagnosis:
Hypertension, Stage 1–2 (I10)
o Patient is showing improved but still elevated BP.
o Likely essential hypertension, no signs of secondary causes.
o Responding to initial Lisinopril therapy, but not yet at target
(<130/80).
Comorbidities:
Hyperlipidemia
Obesity
🔍 5. Differential Diagnoses
1. Essential Hypertension – most likely; confirmed by prior reading
and current patterns.
2. Secondary Hypertension (e.g., renal, endocrine) – less likely, no
red flags.
3. White Coat Hypertension – possible contributor; home readings
are better.
4. Medication Nonadherence – unlikely, patient reports compliance.
5. Masked Hypertension – opposite of white coat, less likely here.
📋6
Past Medical History (PMH):
, Hypertension (diagnosed 2 weeks ago)
Hyperlipidemia (diagnosed 2 years ago)
Obesity (BMI ~32)
No history of diabetes
No known cardiovascular disease
Past Surgical History (PSH):
Appendectomy in her 20s
Tubal ligation in her 30s
. Plan (SOAP “P”)
Medications:
Continue Lisinopril 10 mg daily
Consider titration to 20 mg daily if BP remains above goal in 2–4
weeks
Monitor electrolytes and renal function (BMP/CMP) 1–2 weeks
after any med change
Lifestyle Modifications:
Continue DASH diet: low sodium, rich in fruits/vegetables
Encourage weight loss (target 5–10% reduction)
Physical activity: At least 150 minutes of moderate-intensity
aerobic exercise/week
Limit alcohol (≤1 drink/day for women)
Monitoring:
Home BP log: check 2x/day, log readings
Recheck in 2–4 weeks
Watch for cough, dizziness (possible Lisinopril side effects)
