NR 509 Week 5 iHuman Virtual Patient Encounter Attempt 3816706 - Felipa Garcia
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History Notecard by Shania Turner 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= Hypertension Sx= Sx= Sx= Sx= Sx= CC Provided How can I help Recently at community health fair you? with hypertension 170/92. Any other Denies any other symptoms symptoms? HPI Onset/events pt unsure Location Duration Characteristics Denies chest pain, SOB or palpations Aggravating Reliving Severity What this means Attempt: 3816706 Report generated on 2/8/2026, 12:44:47 PM America/Denver Management Plan by Shania Turner on case Felipe Garcia Diagnostic: Felipe Garcia, a 57 year-old male presents with primary hypertension. Diagnostic tests are normal to rule out secondary hypertension; normal ECG, normal CBC, normal CMP, normal TSH, normal UA. Blood pressure on the right arm 178/98, left arm 172/92, HR 76. Pt complains of gastritis occasionally as well, likely due to dietary choices and lifestyle. History of ACL repair to the right knee. Occasional achy knees due to work and PMH. Medication/treatment: Due to second grade hypertension. It is recommended to start pharmacological therapy immediately. Elevated blood pressure is associated with an increased risk of major cardiovascular events. (Hellgren, et al., 2023). First line antihypertensive medications: Amlodipine 5mg PO once daily. 30 day supply. No refills. Reassess on follow up. Continue PRN over-the-counter Omeprazole 20 mg PO, PRN for gastritis. Take as directed on the label. Knee discomfort : discontinue ibuprofen due to risk factors. Risk factors contribute to the development of gastritis or GERD. These include obesity, dietary factors, such as caffeine, spicy food, smoking, and the use of NSAIDS (Odah. et al., 2021). Recommend: Tylenol 500mg. 2 tabs every 6 hours. PRN for knee pain. Do not exceed 4,000mg in 24hrs. Liver warning may occur if more than 4,000mg of acetaminophen in 24 hours or in combination with alcohol. Education: Possibly referral to dietary education. Life style modifications(non-pharmacological) are weight loss, possible daily walks when able with knee discomfort. Diet: including fruits, vegetables, whole grains and low-fat dairy products, reduced saturated and limited sodium. Exercise recommended about 30 mins of moderate-intensity such as swimming or walking. Reduction of alcohol on the weekends. Blood pressure- Dietary recommendations such as reduction in sodium intake, moderation of alcohol, weight loss and strive for a diet high in fruits, vegetables, legumes and low fat dairy products. Non-dietary modifications include cessation of smoking and implementation of an aerobic exercise regimen. Follow up: Monthly follow up until blood pressure is controlled. Follow up sooner if you develop side effects to medications. Reference: Hellgren, M., Wennberg, P., Hedin, K., Jansson, S., Nilsson, S., Nilsson, G., Wändell, P., & Bengtsson Boström, K. (2023). Hypertension management in primary health care: a survey in eight regions of
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