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Class 6512: I Human Case Week #7 56 Year Old Female Reason For Encounter: Blood Pressure Recheck FEMALE HEIGHT: 5โ5โ (165 CM)WEIGHT: 188.0 LB (85.5 KG)REASON FOR ENCOUNTER: BLOOD PRESSURE RECHECK LOCATION: OUTPATIENT CLINIC WITH LABORATORY CAPABILITIES
I-HUMAN CASE: WEEK #7 โ
CASE STUDY WRITE-UP
Patient: 56 - year-old female Height: 5 โ5โ (165 cm) Weight: 188 lbs (85.5 kg) BMI: 31.3 (Obese โ Class I) Reason for Encounter: Blood Pressure Recheck Setting: Outpatient Clinic with Laboratory Capabilities Course: Class 6512 Date: 2025 I. SUBJECTIVE DATA
Chief Complaint (CC): โI came in to get my blood pressure checked again.โ History of Present Illness (HPI): The patient is a 56-year-old female presenting for a follow-up blood pressure evaluation. She was previously noted to have elevated readings and was asked to return for monitoring. She reports occasional mild headaches and intermittent dizziness, especially in the mornings. She denies chest pain, palpitations, dyspnea, or visual disturbances. Past Medical History (PMH):
- Hypertension (recently diagnosed)
- Hyperlipidemia
- Siblings: One brother with hypertension Social History:
- Tobacco: Never
- Alcohol: Occasionally (1โ2 drinks/week)
- Drugs: Denies illicit drug use
- Diet: High in processed foods, low vegetable intake
- Exercise: Sedentary lifestyle
- Occupation: Office administrator
- Marital Status: Married Review of Systems (ROS):
- General: No fever, chills, or weight changes
- HEENT: Mild morning headaches, no visual changes
- Cardiac: No chest pain or palpitations
- Respiratory: No SOB or cough
- GI: No nausea, vomiting, or abdominal pain
- GU: No dysuria, normal urinary pattern
- Neuro: Occasional dizziness
- Psych: Denies anxiety or depression II. OBJECTIVE DATA Vital Signs:
- BP: 152/94 mmHg (sitting, right arm)
- HR: 78 bpm
- Temp: 98.4ยฐF
- RR: 16/min
- O2 Sat: 98% RA
- BMI: 31.
(Include labs or note "Pending" if no data was provided in the case) Most recent labs:
- CBC: WNL
- CMP: WNL
- Lipid Panel: o Total Cholesterol: 220 mg/dL o LDL: 140 mg/dL o HDL: 45 mg/dL o Triglycerides: 180 mg/dL
- Fasting Glucose: 99 mg/dL
- A1c: 5.8% IV. ASSESSMENT Differential Diagnoses:
- Primary Hypertension - uncontrolled (most likely)
- Metabolic Syndrome โ due to obesity, dyslipidemia, elevated BP
- White Coat Hypertension
- possible, but less likely given symptoms and history
- Secondary Hypertension (e.g., renal or endocrine) โ less likely, but worth ruling out in persistently high readings V. PLAN Diagnostics:
- Ambulatory BP monitoring or home BP log
- Repeat lipid panel in 3 months
Follow-Up:
- Recheck BP in 2โ4 weeks
- Return visit in 1 month for medication adjustment if needed
- Lab follow-up in 3 months Education:
- Educated patient on hypertension risks and lifestyle changes
- Provided pamphlet on low- sodium diets
- Discussed medication side effects and importance of adherence VI. REFLECTION This case emphasizes the importance of not only identifying hypertension but also
addressing the broader context, including obesity, diet, and lipid abnormalities. It was essential to use both patient-reported symptoms and objective findings to guide management, and I learned how critical follow-up and patient education are in managing chronic conditions.
. Absolutely! Here's a more detailed Assessment and Plan section with additional diagnoses and an expanded treatment plan , reflecting best practices as of 20 25 guidelines. IV. ASSESSMENT (Expanded)
fasting glucose)
- Risk of Cardiovascular Disease
- Multiple modifiable risk factors R/O (Rule Out):
- Secondary Hypertension โ such as renal artery stenosis, hyperaldosteronism, or thyroid dysfunction, if no improvement with initial therapy
- OSA (Obstructive Sleep Apnea) โ if patient reports snoring, daytime sleepiness, or fatigue
- NAFLD (Nonalcoholic Fatty Liver Disease) โ if abnormal LFTs noted in future labs V. PLAN (Expanded)
Diagnostics:
- Ambulatory BP Monitoring (ABPM) or Home BP Monitoring : Confirm diagnosis and assess white coat effect
- Repeat Lipid Panel : In 3 months after lifestyle and medication changes
- TSH, T4 : Rule out thyroid cause of hypertension
- Renal function panel + Electrolytes : Monitor for thiazide side effects and renal status
- Urinalysis and microalbumin : Screen for early nephropathy
- Sleep Study Referral (if OSA symptoms present)
o Consider Metformin 500 mg BID if A1c trends up and other risk factors persist
- Aspirin 81 mg daily โ low-dose if 10 - year ASCVD risk >10% (evaluate using ASCVD Risk Calculator) Lifestyle & Behavioral Recommendations:
- Dietary: o Initiate DASH diet โ rich in fruits, vegetables, low-fat dairy, whole grains o Limit sodium to <1500 mg/day o Reduce saturated fats and sugars
- Weight Loss:
o Goal: 5โ10% reduction in body weight over 6 months (~9โ18 lbs)
- Physical Activity: o Minimum: 150 minutes of moderate-intensity aerobic activity per week o Strength training 2x/week
- Sleep Hygiene: o Screen for insomnia or sleep apnea
- Stress Management: o Recommend yoga, mindfulness, or counseling as needed
- Alcohol & Caffeine: o Limit alcohol to โค1 drink/day o Monitor caffeine intake if associated with elevated BP
