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I-Human Case Study Week 4 (Class 6512) | Clinical Assessment and SOAP Note Example | 2025 Edition

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This I-Human Case Week 4 report presents a full SOAP note and differential diagnosis for a 56-year-old female evaluated for high blood pressure and low back pain. Includes patient history, physical exam, assessment, and evidence-based plan. Ideal for NP and RN students learning case documentation and clinical reasoning.

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I HUMAN CASE WEEK #4 CLASS 6512

I Human Case Week #4 56 Year Old
Female Reason For
Encounter: Blood Pressure Recheck
class 6531 Case Study 6512
I – Human Case Study Week #4 Class


56 Year Old Female

Height: 5.5 (165cm)

Weight: 188.0 LB(85.5 KG)

Reason for encounter



Case Instructions
By submitting this a
that the work contai


CASE REVIEW CASE PLAY SETUP
1880 1b (855 kg) A




MODE:
Reason for encounter
Blogd.pressure recheck

, I HUMAN CASE WEEK #4 CLASS 6512

Pivotal
Concept Category Question Response
Addressed
I was recently at a health fair
in my community where I had
my blood pressure checked.
The nurse told me that I
should
How can I help you today? see a I doctor think she
because said 170/92 my
pressure or somethingis too
high.
like that. Do those numbers
sound right? Anyhow, my
wife was concerned and
made the appointment.
Do you have any other No, not really.
symptoms or concerns we
Should discuss?
I don't know. I remember some
doctor years ago saying I
start? should watch my diet because
my pressure was a bit
pressure? high...but I felt well and really
didnt pay him much attention.

High enough that the nurse
Does anything make your urged me to come in.
high blood pressure better or
worse? I don't know. I haven't been
paying any attention.
What treatments have you I dorñ have a regular doc. This
had for your high blood is really my first visit.
pressure?
What treatments have you had for
HPI the pain in your knee(s)?

, I HUMAN CASE WEEK #4 CLASS 6512

PMH Does anything make the pain
in your knee(s) better or
worse?
PMH Can you tell me about any Other than the high blood
pressure I mentioned, I dont
current or past medical
think I really have any.
problems you have had? Maybe just a little bit of acid
Do you have high stomach.
cholesterol? Somebody told me I had
gastritis once. And I have achy
Any previous medical,
knees. I don't really see a
surgical or dental doctor on a regular basis, just
procedures? when I need to.
PMH I dont know.
I had my ACL repaired in my
right knee. Nothing else.
PMH Are your immunizations up to
date?
PMH
Have you had a flu shot this
year?
Grandparents
Paternal: Paternal grandfather 81, HTN, DM; Paternal
grandmother 76 history of DM and Ml.
Maternal: Maternal grandfather died at 82 from Ml, maternal
grandmother 79, history of diabetes and arthritis.

Parents
Father: Father 59, history of H TN, Diabetes, Depression, and
Stroke. Mother: Mother 52, died in a MVA.

Siblings
Siblings:Only child.
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