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Summary FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE 2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS, PLAN, AND SUMMURYR567,77
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Summary FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE 2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS, PLAN, AND SUMMURY
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FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH
Institution
FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH
FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE 2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS, PLAN, AND SUMMURY
FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE
2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS,
PLAN, AND SUMMURY
FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE
2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS,
PLAN, AND SUMMURY
, FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE
2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS,
PLAN, AND SUMMURY
Patient Information
Name: Felipe Garcia
Age: 57
Gender: Male
Chief Complaint
High blood pressure
History of Present Illness (HPI)
Symptoms:
o Headaches (dull, improved with ibuprofen, occurring in the morning)
o Stomach burning sensation
o Difficulty breathing with exertion
o Recent weight gain
Medication Use:
o Ibuprofen 4-5 pills a day, 2-3 times a week
Past Medical History (PMH)
Chronic Conditions:
o GERD
o Right knee ACL repair
Family History:
o Father: Stroke at age 62
o Mother: Diabetes
o Brother and uncle: High blood pressure
Social History:
o Smoking: 1 pack/day for 20 years
o Alcohol: Drinks on weekends
o Recent weight gain
Vital Signs
Temperature: 98.6°F
Blood Pressure: 170/92 mmHg
Pulse: 70 bpm
FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE
2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS,
PLAN, AND SUMMURY
, FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE
2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS,
PLAN, AND SUMMURY
Respirations: 14/min
SpO2: 96% on room air
Admission Orders
1. Diagnosis:
o Essential Hypertension
o Obstructive Sleep Apnea
2. Admission:
o To: Medical Surgical Floor
o Physician: Dr. Amber, call upon arrival with room number
3. Isolation/Precautions:
o Standard
4. Allergies:
o No known allergies
5. Diet:
o Cardiac Diet
6. Activity:
o As tolerated
7. IV:
o One saline lock
8. IVF:
o None
9. LABS:
o No additional
10. AM LABS:
o Fasting lipid panel
o CBC
o BMP
11. RADS/Diagnostic Tests:
o ECHO
o Chest X-ray PA
12. Consults:
o Nutrition consult
13. Consult:
o Respiratory therapy
14. Screenings:
o None
15. Medications:
o Chlorothiazide (Diuril) 250 mg twice a day
o Albuterol sulfate nebulizer 5 mg treatments every 6 hours as needed for SOB or
wheezing
o Omeprazole 20 mg daily
FELIPE GARCIA I-HUMAN CASE STUDY 57-YEAR-OLD WITH HIGH BLOOD PRESSURE COMPLETE
2024 CASE STUDY WITH HISTORY, PHYSICAL EXAM, ASSESSMENT, TEST RESULTS, DIAGNOSIS,
PLAN, AND SUMMURY
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