NR 509 Week 5 iHuman Virtual Patient Encounter Attempt 3434313 - Felipe Garcia
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History Notecard by Kaleigh Bell on case Felipe Garcia Use this to collect your thoughts to develop a differential diagnosis list. Step 1: Write symptoms (Sx) you have identified in the appropriate column and row. Step 2: Characterize the symptoms using "OLDCARTS" (ie., Onset, Location, Characteristics...etc) in the HPI section. Step 3: Record your thoughts in the space labeled "What this means". Is the disease acute or chronic? Infectious or other?... Timing/treatments Hx Categories Heartburn Achy Sx=Sx=Sx=Sx= knees CC Provided How can I help you? Any other symptoms? HPI Onset/events several years ago Location up bilateral in knees center, stomach Duration until until pt takes taking omeprazole ibup Characteristics stomach burning Aggravating spicy foods Reliving omeprazole Ibuprofen Severity 2/10 achy What this means Attempt: 3434313 Report generated on 2/10/2025, 1:00:57 AM America/New_York Management Plan by Kaleigh Bell on case Felipe Garcia 1. Diagnostic Tests: ECG, CBC, CMP, TSH, and UA 2. Medication/Treatment: According to clinical practice guidelines, appropriate medications for this patient include: Hydrochlorothizide 25 mg tablets, take one tablet by mouth daily, dispense #30 with no refills and Lisinopril 10 mg tablets, take one tablet by mouth daily, dispense #30 with no refills (Whelton et al., 2018). Advise patient to watch for signs of hypotension including dizziness, lightheadedness, blurred vision, fainting. In adults with stage two hypertension, drug therapy with two first line agents of different classes is recommended (Whelton et al., 2018). 3. Consults/Referrals: A risk factor for hypertension is obstructive sleep apnea. Untreated OSA can lead to serious health problems including heart disease, stroke, and elevated blood pressure (Rogers, 2020). Recommendation to refer patient for a sleep study to check for obstructive sleep apnea since patient reports no prior sleep study. 4. Education: Educate patient on their diagnosis of primary hypertension, test results and education patient on how to perform at home blood pressure monitoring as blood pressure readings are often higher in the office setting than at home (Whelton et al. 2018) Educate patient on effective lifestyle modifications including smoking cessation, dietary changes (DASH diet), weight loss, regular exercise, sodium restriction, potassium enrichment, and moderation of alcohol use to reduce the risk of cardiovascular disease. (Clarke, 2023). Educate patient on decreasing NSAID use and trying alternative options like Acetaminophen or topical NSAIDs to reduce the risk of renal injury (Whelton et al., 2018). 5. Follow up: Schedule a one month follow up to assess patient's blood pressure, compliance, any adverse reactions and to refill or adjust prescriptions. Guidelines recommend patients follow up monthly when taking antihypertensive medications until blood pressure is controlled. Once the blood pressure is controlled, the patient can schedule follow ups every 3-6 months (Clarke, 2023). Advise patient to call the clinic if any concerns or questions prior to scheduled follow up appointment. 6. References Clarke, S. L. (2023). Hypertension in adults: Initial evaluation and management. American Family Physician, 108(4), 352-359 Rogers, J. (2020). Understanding the most commonly billed diagnoses in primary care: Hypertension. The Nurse Practitioner, 45(6), 50-55. doi: 10.1097/01.NPR.0000666196.20382.57 Whelton, P.
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