I Human Case Week #5 A 57 Year Old Male Reason For
Encounter: Elevated Blood Pressure Comprehensive Case
Plan
performance Overview for Tonya Ames on case Anselmo Lopez
The following table summarizes your performance on each section of
the case, whether you completed that section or not.
Time spent: 1dy 8hr 58min 39sec
Status: Submitted
Your Time spent
Case Section Status Performance Details
Score
Total Score 69%
History Done 92%
44 questions asked, 11 correct, 1 missed relative
26min 51sec
to the case's list
Done 35% 35 exams performed, 13 correct, 2 partially
Physical exams 16min 5sec correct, 30 missed relative to the case's
list
Done 7 findings listed; 11 listed by the case
Key findings 2min
organization 20sec
Problem Done 112 words long; the case's was 84 words
1dy 4hr
Statement
29min
18sec
Diagnosis Done 100% 58sec
Done 2hr 917 words long; the case's was 280 words
Management 9mi
Plan n
6sec
Exercises Done 2min 1sec 0 of 1 correct (of scored items only)
86%
1 partially correct
(of
scored
items
only)
History Notecard by Tonya Ames 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
Problem Statement by Tonya Ames on case Anselmo Lopez
57 year old male, construction/flooring worker, without previous medical records and absent from
preventative health screenings for several years. Patient self reports history of acid
reflux treated with OTC omeprazole, bilateral knee pain treated with OTC ibuprofen.
Surgical history of ACL repair, unknown date. Patient without well balanced nutrition, consumes
elevated processed foods high in fat and sodium. Patient presents to office today for
evaluation of elevated blood pressure reading, approximately 170/92, at community wellness
event. Patient denies history of hypertension or cardiac disease. Blood pressure in office is
elevated L:172/94 R: 178/98. Patient denies palpitations, chest pain, dizziness, SOB or cardiac
history. Significant family history for Diabetes, HTN, Stroke, and MI.
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