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. [Show More]
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