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NR 509 Week 5 iHuman Virtual Patient Encounter Attempt 3811393 - Felipa Garcia

Chamberlain University Nursing NR 509 Advanced Physical Assessment Laci Peterson 8 pages
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History Notecard by Dara Heaston 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 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: 3811393 Report generated on 2/2/2026, 7:01:42 PM America/Denver Management Plan by Dara Heaston on case Felipe Garcia Subjective Mr. Felipe Garcia is a 57-year-old male who presents for evaluation of elevated blood pressure after being told at a community health fair that his blood pressure was “high.” He denies chest pain, shortness of breath, cough, orthopnea, edema, or fatigue. Past medical history is significant for gastritis and chronic knee joint pain. He reports smoking with a 35-pack-year history and drinks alcohol on weekends. Diet consists primarily of fast food with high salt and fat content. Family history is positive for hypertension and coronary artery disease. Past Surgeries include prior ACL repair. Current medications include over-the-counter omeprazole and ibuprofen. Objective Vital Signs: Height: 69 in | Weight: 195 lbs | BMI: 28.8 BP: 172/94 mmHg (left arm), 178/98 mmHg (right arm) HR: 76 bpm | RR: 16 | Temp: 37.0°C | SpO₂: 98% Physical Exam: General: Overweight male in no acute distress HEENT: Symmetric, without trauma; arteriovenous nicking noted Neck: no cervical lymphadenopathy, trachea midline, adequate ROM no pain with movement Cardiovascular: Regular rate and rhythm, S1/S2 normal, no murmurs, pedal pulses +2 bilaterally Respiratory: Clear to auscultation bilaterally, respirations even and unlabored Abdomen: Obese, soft, non-tender, bowel sounds present Musculoskeletal: Bilateral knee tenderness with limited range of motion; strength 5/5 in all extremities Neurologic: Alert and oriented ×3; cranial nerves 2-12 intact Skin: Warm, dry, intact Diagnostics: EKG: Normal sinus rhythm, HR 75 Labs: WBC, CMP, UA, TSH all within normal limits Assessment Uncontrolled Stage 2 Hypertension (BP ≥140/90 mmHg) Overweight (BMI 28.8) Tobacco use disorder Chronic bilateral knee pain Increased cardiovascular risk due to age, smoking history, obesity, and family history of CAD Plan: Initiate antihypertensive therapy: Lisinopril/Hydrochlorothiazide 10/12.5mg Take one tablet by mouth once daily # 30 with no refills Education: Limit NSAID Use Electronic Health Record by Dara Heaston on case Felipe Garcia History of Present Illness Category Data entered by Dara Heaston Reason for Encounter Physical Exam High Blood Pressure History of present illness Mr. Felipe Garcia is a 57-year-old male who presents to the office for evaluation of high blood pressure. Patient states that he went to a community health fair and was told this his blood pressure “was high”. Past Medical History Category Data entered by Dara Heaston Past Medical History Reports Gastritis and joint pain Hospitalizations / Surgeries ACL repair Medications

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