Description
NR509 Week 5 iHuman: Anselmo Lopez




π§ββοΈ Interview Summary: Patient: Anselmo Lopez
Chief Complaint (CC):
βI was told at a health fair that I have high blood pressure and need to see a doctor.β
π History of Present Illness (HPI) β High-Yield Questions Asked
-
How can I help you today?
β Patient reported elevated blood pressure found at a community health fair. -
Do you have any other symptoms or concerns?
β Patient denied additional concerns. -
When did your high blood pressure start?
β Patient recalls being told years ago to watch his diet but never followed up. -
How severe is your blood pressure?
β Severe enough that the nurse urged him to see a provider. -
Does anything improve or worsen the high BP?
β Patient unaware; not paying attention to symptoms. -
What treatments have you tried for high blood pressure?
β No prior treatments; this is his first formal visit. -
What treatments have you used for knee pain?
β Ibuprofen. -
What improves the knee pain?
β Ibuprofen helps relieve the pain.
π₯ Past Medical History (PMH)
-
Current/Past medical conditions?
β Reports possible past diagnosis of gastritis or acid stomach. ACL repair in right knee. Aches in knees. -
Do you have high cholesterol?
β Unsure. -
Any prior medical/surgical/dental procedures?
β Had ACL surgery in the right knee. -
Are your immunizations up to date?
β Completed childhood immunizations. -
Did you receive a flu shot this year?
β No.
π©Ί Physical Exam Summary
All vital signs and general exams were performed correctly, with one partially correct exam noted.
| Exam Performed | Status |
|---|---|
| Cognitive status | β Performed Correctly |
| Blood pressure | β Performed Correctly |
| Pulse | β Performed Correctly |
| Respiration | β Performed Correctly |
| Temperature | β Performed Correctly |
| SpOβ | β Performed Correctly |
| Test visual acuity | β Performed Correctly |
| Inspect eyes | β Performed Correctly |
| Examine pupils | β Performed Correctly |
| Perform ocular motor test | β οΈ Partially Correct |
| Perform funduscopic exam (ophthalmoscope) | β Performed Correctly |
…………..add to cart and checkout to purchase the patient history, physical exam, EHR, and management plan at $30 only

Customer Reviews
There are no reviews yet.