Download (CLASS 6512)I-HUMAN CASE WEEK 7 56 Y/O FEMALE HEIGHT: 5’5” (165 CM)WEIGHT: 188.0 LB (85.5 and more Exams Health sciences in PDF only on Docsity!
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(CLASS 6512)I-HUMAN CASE WEEK 7 56 Y/O FEMALE
HEIGHT: 5’5” (165 CM)WEIGHT: 188.0 LB (85.5 KG)REASON FOR
ENCOUNTER: BLOOD PRESSURE RECHECK LOCATION:
OUTPATIENT CLINIC WITH LABORATORY CAPABILITIES LATEST
Patient Profile: Age: 56 years old Gender: Female Height: 5’5” (165 cm) Weight: 188.0 lbs (85.5 kg) Reason for Visit: Blood pressure recheck Location: Outpatient clinic with laboratory capabilities Mode: Learning Mode (feedback appears after each section)
2 Attempts Available: 1 i- Human Case Week 7 Preview Patient Info (Top Left Panel): Photo: Female patient (appears middle-aged) Age: 56 y/o Height: 5'5" (165 cm) Weight: 188.0 lb (85.5 kg) Reason for Encounter: Blood pressure recheck Location: Outpatient clinic with laboratory capabilities Right Panel: Case Instructions Title: H&P+Dx Case Play Setup and Instructions Mode: Learning Mode o Feedback is provided after submitting each section. Attempts Allowed: o 1 attempt permitted for this assignment Sample History for i-Human Case 7: Blood Pressure Recheck HPI (History of Present Illness): 56-year-old female presenting for a follow-up to recheck her blood pressure. Denies chest pain, palpitations, dizziness, or syncope. May report occasional headaches or fatigue (check her answers during the interview). Could mention non-adherence to medications, lifestyle changes, or diet. PMH (Past Medical History): Hypertension (diagnosed previously)
3 Check if she’s currently on antihypertensives (like lisinopril, amlodipine, etc.) Over-the-counter meds or supplements? Allergies: Any known drug or food allergies? FH (Family History): Any family history of hypertension, diabetes, stroke, or heart disease? Parents/siblings with cardiovascular risk? SH (Social History): Smokes? (packs/day and duration) Alcohol use? Diet (high sodium or processed food intake?) Physical activity level Occupation and stress levels ROS (Review of Systems): General: Fatigue, weight gain/loss Cardiovascular: Chest pain, palpitations, edema Respiratory: SOB, wheezing Neuro: Headaches, dizziness GU/GI: Changes in urination or digestion Physical Exam + i-Human Case Week 7 General Appearance:
Alert and oriented × Appears stated age No acute distress
Vital Signs: (very important for BP follow-up)
No lesions or ulcers Warm and dry
5 Assessment + i-Human Case Week 7 Primary Diagnosis: Essential Hypertension (ICD-10: I10) Rationale: o Patient is here for a BP recheck. o Previous or current elevated BP readings likely present ( ≥130/80 mmHg). o Risk factors: Age >55, BMI ~31.3 (obese), possible sedentary lifestyle or diet issues. o No secondary causes currently evident on exam or history. Possible Secondary/Supporting Diagnoses:
- Obesity (ICD-10: E66.9) o BMI ~31.3 based on height/weight. o Major contributor to elevated BP and cardiovascular risk.
2. Hyperlipidemia (ICD-10: E78.5) (if supported by labs)
o Common comorbidity with HTN and obesity.
- Prediabetes/Type 2 Diabetes Mellitus (ICD-10: R73.03 or E11.9)
(if glucose/A1C supports it)
4. Nonadherence to Antihypertensive Therapy (ICD-10: Z91.14) (if
she admits missing meds)
□Tips: Always rank diagnoses in order of importance. Be sure your top diagnosis is fully supported by HPI, PE, and labs. In a BP recheck visit, especially in i-Human, they may want you to rule out secondary causes of HTN if anything seems off (e.g., renal bruit, abnormal thyroid, etc.). Test Results + i-Human Case Week 7
- Blood Pressure Measurement:
- Urinalysis:
7 Proteinuria or hematuria could indicate renal disease secondary to long-standing HTN. Microalbuminuria can also suggest kidney involvement.
- Echocardiogram (if needed): Could reveal left ventricular hypertrophy (LVH) or diastolic dysfunction if HTN has led to heart changes.
- Electrocardiogram (ECG): Check for LVH, arrhythmias (e.g., atrial fibrillation), or signs of ischemia. □Sample Results Based on the Case (Possible i-Human Output): BP: 148/92 mmHg (stage 2 hypertension) Glucose: 102 mg/dL (elevated, possible prediabetes) LDL: 160 mg/dL (elevated, indicating hyperlipidemia) Creatinine: 1.1 mg/dL (normal but needs monitoring with ongoing HTN) Urinalysis: Negative for protein or blood Diagnosis Primary Diagnosis: Essential (Primary) Hypertension ICD-10: I Rationale: o Elevated BP on repeat measurement (e.g., ≥140/90 mmHg) o No signs of secondary hypertension (normal TSH, no renal bruits, etc.) o Risk factors: age >55, obesity (BMI ~31), possibly poor diet or sedentary lifestyle
8 Secondary Diagnoses / Comorbidities:
- Obesity o ICD-10: E66. o BMI ~31.3 based on height/weight o Contributes to hypertension and cardiovascular risk
2. Hyperlipidemia (if labs show elevated LDL or triglycerides)
o ICD-10: E78. o Increases cardiovascular risk; management should be addressed alongside HTN
3. Prediabetes (if fasting glucose 100+125 mg/dL or A1C 5.7+6.4%)
o ICD-10: R73. o Further elevates cardiovascular risk; consider lifestyle and follow-up A1C testing
- Possible Nonadherence to Medication or Lifestyle Recommendations o ICD-10: Z91. o Important to assess for barriers (cost, side effects, understanding) Plan
- Hypertension Management (Primary Diagnosis - I10): Lifestyle Modifications: o DASH diet (low sodium, high fruits/veggies, lean protein) o Sodium restriction: <2,300 mg/day, ideally <1,500 mg/day o Weight loss: Target 5+10% body weight reduction o Exercise: ≥ 150 min/week moderate-intensity aerobic activity o Limit alcohol: ≤1 drink/day (women) o Smoking cessation (if applicable) Pharmacologic Therapy: o Start antihypertensive therapy (if not already prescribed) First-line: Thiazide diuretic, ACE inhibitor, ARB, or CCB Example: Lisinopril 10 mg daily (adjust per labs/BP)
o Monitor for side effects (e.g., ACEi: cough, hyperkalemia, renal function) Monitor BP at home: Keep a log and bring it to follow-up
EKG if any cardiac symptoms or baseline evaluation warranted Annual eye exam for retinal changes (HTN-related)
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- Follow-Up: Return in 2+4 weeks to reassess BP and med tolerance Reinforce medication adherence and lifestyle changes Adjust meds based on home BP log and labs Management Plan
- Lifestyle Modifications: DASH diet: Emphasize fruits, vegetables, whole grains, and low sodium (<1,500+2,300 mg/day). Weight loss: Encourage gradual loss (goal: 5+10% of body weight). Exercise: ≥150 minutes of moderate-intensity aerobic activity per week. Limit alcohol: No more than 1 drink/day. Smoking cessation: Offer counseling/support if applicable.
- Pharmacologic Treatment: Initiate antihypertensive therapy: o Start Lisinopril 10 mg PO daily (or another first-line agent such as a thiazide or CCB, depending on contraindications/labs). o Monitor renal function and electrolytes 1+2 weeks after initiation. Consider statin therapy (e.g., Atorvastatin 20 mg PO daily) based on ASCVD risk factors (age, BP, lipids).
- Patient Education: Educate on: o Importance of medication adherence. o Monitoring BP at home with log. o Potential side effects of meds (e.g., ACE inhibitors). Discuss signs/symptoms that require prompt evaluation (e.g., chest pain, dizziness, swelling).
11 BMP (check potassium and creatinine) in 1+2 weeks after starting ACE inhibitor. Lipid panel to confirm hyperlipidemia and assess need for statin therapy. HbA1c or fasting glucose if not already obtained * screen for prediabetes/diabetes. Optional: EKG if cardiac symptoms or to check for left ventricular hypertrophy.
- Follow-Up: Recheck BP in 2+4 weeks to assess response to treatment. Review home BP readings and medication tolerance. Adjust meds or add additional antihypertensives if BP goal not met. Routine follow-up every 3+6 months once stable. SOAP Note + Week 7 i-Human Case S + Subjective Chief Complaint: “I’m here to have my blood pressure rechecked.” HPI: 56-year-old female presents for a follow-up visit to evaluate previously elevated blood pressure. She reports feeling generally well, with no chest pain, shortness of breath, dizziness, or palpitations. She denies visual changes, headaches, or swelling. She has not been consistently monitoring her blood pressure at home and may not be consistently taking prescribed medication (if applicable). No recent illness or significant lifestyle changes. PMH: Hypertension (diagnosed previously) Possible obesity
Hyperlipidemia or prediabetes (suspected) No history of cardiovascular events
