IHUMAN Case Study Harvey Hoya (A Grade)

History of current Illness
Harvey Hoya is a 57-year-old man with the primary complain of high blood pressure. The
client visited the hospital for blood pressure check. Result suggested that he has high blood
pressure. The attending nurse recommended further assessment by the doctor. The condition
started years ago but the client ignored it since he felt good. The client also complains of
headaches in the morning making him tired the whole day. He loses appetite when headaches
occur. The client also has problems with fatigue, especially during the day. His fatigue does not
improve as evidenced by a lack of good sleep at night. He also experiences a little of breathing
difficulties but denies wheezing and coughing. The client rates the severity of headache to be 3 to
4 out of ten. His blood pressure is elevated.
Past Medical History (allergies, medications, OTC drugs)
The client’s childhood illnesses include tummy aches, colds and usual coughs. He also
had his ACL repaired in his right knee. The client is currently taking Ibuprofen (800 mg 3 times a
day, but 2 to 3 time a week) for the headaches and omeprazole every morning for his stomach.
The client denies having any high blood pressure medications. No known drug allergies. The
client agrees to have received all childhood vaccinations.
Family history
The client agrees that his brother and uncle were both diagnosed with high blood pressure
in their 40s. Fortunately, they are still alive and well. The client’s grandfather died of a heart
attack when he was 52. The client’s father died of stroke when he was 62.
Social history (living situation, death of partner, loss of job etc)
The client has been smoking at least a pack a day since his 20s. He has been smoking for
about 35 years. He drinks coffee in the morning, eat fast food in for lunch and TexMex food for
WEEK 4 iHUMAN VIRTUAL PATIENT ENCOUNTER 2
dinner. He likes chips and watching TV. The client works in the construction, flooring
installation. He believes his work is enough exercise. He also walks his dog around the block
every evening. The client drinks alcohol but not very often, only one weekends.