ACTUAL COMPREHENSIVE I- HUMAN CASE STUDY, Exams of Laboratory Practices and Management

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Blood pressure recheck

i-Human Case Study · Class 6512 · Outpatient clinic — BP monitoring, ECG & laboratory 56 y/o male 5'10" (178 cm) · 210 lb (95.3 kg) BMI 30.1 — Obese I BP 162/98 — Stage 2 HTN Established patient · follow-up

Location & clinical setting ▾

FACILITY Outpatient primary care clinic with on- site BP monitoring, 12-lead ECG, and laboratory capabilities VISIT TYPE Established patient — scheduled chronic disease management / BP recheck PROVIDER Primary care physician (PCP) or family NP — outpatient office BP MONITORING PROTOCOL Patient seated ×5 min before reading. Right arm. Appropriate adult cuff. Two readings 2 min apart — average recorded. Serial readings at triage and end of visit. ECG AVAILABILITY 12-lead ECG performed in-clinic this visit — screening for LVH, ischemia, and arrhythmia given Stage 2 HTN and symptoms. URGENCY & DISPOSITION Hypertensive urgency — no acute end- organ damage identified. Managed outpatient. No ED transfer. Billed: 99214 (established, moderate- high complexity). IN-CLINIC CAPABILITIES USED THIS VISIT Serial BP monitoring 12-lead ECG BMP / CMP CBC Fasting lipid panel HbA1c (POC) Urinalysis + uACR TSH Fingerstick glucose Send-out: plasma aldosterone/renin ratio (ARR). ABPM kit dispensed at discharge. Polysomnography referral placed.

Vital signs ▾

Blood pressure (avg ×2)

Stage 2 HTN — right arm, seated Heart rate

84 bpm

Regular rhythm Respiratory rate

16/min

Within normal limits Temperature

98.2°F

Afebrile SpO₂

Room air Weight

210 lb

95.3 kg BMI

Obese class I Repeat BP at end of visit after resting: 158/96. Consistent with true hypertension — not white coat.

Review of systems (ROS) ▾

POSITIVE NEGATIVE Occipital/frontal headaches — worst on wakingNo chest pain or pressure Orthostatic lightheadedness / dizzinessNo diaphoresis Mild dyspnea on exertion (stairs)No syncope or near-syncope Fatigue, poor sleep qualityNo vision changes / diplopia Loud snoring; partner reports apnea episodesNo palpitations Nocturia ×1–2 (possible OSA / early CKD)No lower extremity edema Occasional epistaxis (nosebleeds)No focal neurological deficits No dysuria or hematuria

Physical examination ▾

General Well-appearing, overweight male in no acute distress; cooperative and appropriate HEENT Normocephalic/atraumatic. Fundoscopy: mild AV nicking bilaterally, arterial narrowing — Grade 1– hypertensive retinopathy. No papilledema. No flame hemorrhages. Neck Supple. No JVD at 30°. No carotid bruits. No thyromegaly or lymphadenopathy. Neck circumference 17 in (OSA risk). Cardiovascular Regular rate and rhythm. S1/S2 intact. Possible S4 gallop (suggests reduced LV compliance — LVH screen). No murmurs or rubs. Peripheral pulses 2+ bilaterally. No peripheral edema. Respiratory Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Abdomen Soft, non-tender, non-distended. Central/abdominal obesity. No renal or aortic bruits. No hepatosplenomegaly. Waist circumference 40 in (metabolic syndrome criterion). Extremities No pitting edema. No clubbing or cyanosis. Cap refill <2 sec. Dorsalis pedis pulses intact bilaterally. Neurological Alert and oriented ×3. CN II–XII grossly intact. No focal motor or sensory deficits. Gait normal. Skin No xanthomas. No acanthosis nigricans. Warm and intact. Notable exam finding: Possible S4 gallop — suggests early LV hypertrophy from chronic pressure overload. Warrants ECG (in- clinic today) and echocardiogram if ECG shows LVH voltage criteria.

ECG findings (performed in-clinic this visit) ▾

RATE & RHYTHM Rate 84 bpm Rhythm Normal sinus rhythm (NSR) PR interval 168 ms (normal < ms) QRS duration 96 ms (normal <120 ms) QTc 432 ms (normal) MORPHOLOGY FINDINGS Axis LVH criteria ST changes Normal axis (0–90°) Sokolow-Lyon: S in V

• R in V5 = 38 mm — borderline positive for LVH (>35 mm) No ST elevation or depression T waves No acute T-wave inversions Q waves No pathological Q waves ECG interpretation: Normal sinus rhythm. Borderline LVH by Sokolow-Lyon voltage criteria (38 mm). No acute ischemic changes. Findings consistent with chronic pressure overload from uncontrolled HTN. Recommend echocardiogram to confirm LVH and assess LV function.

Laboratory results (in-clinic, same visit) ▾

Additional workup ordered ▾

COMPLETED THIS VISIT ORDERED / REFERRED Serial BP monitoring ×2 (confirmed 162/98 and 158/96) Echocardiogram — confirm LVH, assess LV function and 12-lead ECG — borderline LVH (Sokolow-Lyon 38 mm) wall thickness BMP, HbA1c, lipid panel, TSH, UA + uACRPolysomnography referral — OSA evaluation CBC (pending same day)Plasma aldosterone/renin ratio (send- out) ABPM kit dispensed at dischargeOphthalmology referral — hypertensive retinopathy grading Dietary counseling referral — sodium reduction, alcohol counseling

Management plan ▾

PHARMACOLOGICAL 1 Increase lisinopril to 20–40 mg daily. ACEi remains first-line; creatinine 1.2 and eGFR 68 are acceptable — monitor renal function at 1–2 weeks after dose increase. 2 Add amlodipine 5 mg daily (CCB). Stage 2 HTN requires combination therapy. CCB + ACEi is guideline-preferred (JNC 8, AHA 2017). Avoids thiazide given metabolic syndrome / pre-diabetes concern. 3 Intensify statin: increase atorvastatin from 20 mg to 40 mg nightly. LDL 148, HDL 38, TG 204 — above goal for a patient with hypertension + metabolic syndrome + former smoker (moderate-high ASCVD risk). 4 Discontinue ibuprofen — switch to acetaminophen PRN for headaches. NSAIDs raise BP by 3–5 mmHg, antagonize ACEi, and are nephrotoxic. This is a critical medication reconciliation finding. 5 Continue aspirin 81 mg daily and omeprazole 20 mg daily. NON-PHARMACOLOGICAL 6 Alcohol reduction counseling — target ≤1–2 drinks/day. Current intake (2–3 nightly) is a direct BP driver. Each drink reduction can lower SBP by 1–2 mmHg. 7 DASH diet — sodium <2.3 g/day; reduce processed foods, restaurant meals; increase fruits, vegetables, potassium-rich foods. Can lower SBP 8–14 mmHg. 8 Aerobic exercise — 30 min moderate intensity ≥5 days/week. Lowers SBP 5–8 mmHg; also addresses metabolic syndrome and pre-diabetes. 9 Weight reduction goal — 5–10% of body weight. Each 10 kg lost reduces SBP 5–20 mmHg and improves lipid profile and insulin sensitivity. 10 Medication adherence — provide pill organizer and blister pack, set phone alarms, brief motivational interviewing at this visit. Review adherence barriers (travel schedule). 11 OSA evaluation — polysomnography placed. CPAP if confirmed; reduces BP 2–4 mmHg and major cardiovascular event risk.

FOLLOW-UP & MONITORING 12 Return in 2–4 weeks for BP recheck after medication adjustment and NSAID discontinuation. BP target: <130/80 mmHg (AHA 2017). 13 Check BMP (creatinine, K+) in 1–2 weeks after lisinopril dose increase — monitor for hyperkalemia and acute kidney injury. 14 Home BP log via ABPM — review log at follow-up. Confirm true hypertension vs. white coat effect out of clinic. Patient education: Discontinue ibuprofen — explain it raises BP and harms kidneys. Signs of hypertensive emergency (severe HA, vision loss, confusion, chest pain, facial droop, slurred speech) → call 911. Untreated Stage 2 HTN with borderline LVH significantly increases stroke, MI, and heart failure risk.

ASCVD risk summary & clinical pearls ▾