I-Human Clinical Case Study Week 7 57-Year-Old Male With

I-HUMAN CLINICAL CASE STUDY WEEK 7 - 57-YEAR-OLD MALE WITH UNCONTROLLED HYPERTENSION AND DYSLIPIDEMIA | STEP-BY-STEP EVIDENCE-BASED CARE COMPREHENSIVE MEDICAL CASE STUDY: FELIPE GARCIA SECTION 1: CASE IDENTIFICATION & ADMINISTRATIVE DATA Patient Demographics: Name: Felipe Esteban Garcia Age: 57 years Date of Birth: April 15, 1967 Sex: Male Race/Ethnicity: :ispanic/Latino Marital Status: Married Occupation: Construction Project Manager Insurance: Private PPO (Aetna) Primary Language: English (fluent), Spanish (native) Religion: Roman Catholic Advance Directives: None on file Date of Encounter: October 26, 2024 Time of Encounter: 10:15 AM Type of Visit: Established patient, follow-up Referring Provider: Self-referred Chief Complaint: "My blood pressure is still too high" SECTION 2: SUBJECTIVE DATA 2.1 Chief Complaint (CC) "Uncontrolled blood pressure readings at home for 3 months" 2.2 History of Present Illness (HPI) OPQRST Format: Onset: Gradual recognition over past 3 months through home monitoring Provocation/Palliation: Worse with work stress, alcohol consumption. No clear palliation noted. Quality: Asymptomatic hypertension Radiation: Not applicable Severity: Stage 2 hypertension consistently (150-162/92-98 mm:g) Timing: Persistent throughout day, no diurnal pattern noted OLDCARTS Format: Onset: 3 months of persistent elevation Location: Systemic Duration: Constant finding Character: Asymptomatic elevation Aggravating Factors: Stress, high-sodium meals, alcohol intake, missed medications Relieving Factors: None identified