NR 509 Week 5 iHuman Virtual Patient Encounter Attempt 3690949 - Anselmo Lopez
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History Notecard by Florence Capili on case Anselmo Lopez 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 Sx= Sx= Sx= Sx= Sx= Sx= CC Provided How can I help you? Any other symptoms? HPI Onset/events Location Duration Characteristics Aggravating Reliving Severity What this means Attempt: 3690949 Report generated on 10/5/2025, 10:08:47 PM America/Denver Management Plan by Florence Capili on case Anselmo Lopez Diagnostics: 12-lead electrocardiogram (EKG), complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), and urinalysis (U/A) Medication/ Treatment: The American College of Cardiologists (ACC) and the American Heart Association (AHA) together with other related organizations have established guidelines in the diagnosis and management of hypertension (HTN). Once a diagnosis for hypertension (HTN) has been established, it is important to stage it to determine the course of treatment (Whelton et al., 2018). For this case, the patient has HTN Stage II (SBP >/= 140 or DBP >/=90). According to the guidelines, start the patient on pharmacologic therapy immediately (Heidari et al., 2022). Starting BP lowering regimen with two first- line drugs of different drug classes are suggested for adults with Stage II HTN (Armstrong, 2018). Lisinopril 10 mg tablets: Take one tablet by mouth daily for 30 days. #30 No refills. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor that has been used to control HTN and lower risk for cardiovascular compromise (Lopez et al., 2023). Amlodipine 5 mg tablets: Take one tablet by mouth daily for 30 days. #30 No refills. Amlodipine is a calcium channel blocker (CCB) that has been used to manage HTM and other related conditions (Bulsara & Cassagnol, 2023). For the patient’s complaint of stomach acid, I will continue to prescribe what he has been using that has been helpful: Omeprazole, 20 mg capsules. Take one capsule by mouth daily before breakfast. Omeprazole is a proton- pump inhibitor (PPI) that is used to manage several conditions including simple heartburn (Shah & Srivastava, 2023). For the patient’s complaint about knee pain, I will recommend what has already been helping him in the past: Ibuprofen, 200 mg tablets. Take two tablets by mouth every six hours as needed for mild-moderate pains. Ibuprofen is a non-steroidal antiinflammatory drug (NSAID) that is used to manage musculoskeletal pain (Trung & Bajaj, 2024). Consults/ Referrals: None currently. Education: Lifestyle modification is the most important aspect of essential HTN control (Moiz et al., 2024). The DASH diet with low sodium dietary intake and is recommended to manage HTN (Carey et al., 2021). Moderate intensity aerobic training with resistance training is also recommended to significantly lower BP (Moiz et al., 2024). Weight loss is also recommended to decrease BP in overweight or
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