Larry Garcia HTN
History and Physical
Name
Larry Garcia
Date
Gender
M
Allergies
DOB
12/21/1965
Age
45
Chief Compaint (CC)
“I feel fine, but they tell me my blood pressure is too high.”
History of Present illness (HPI)
Newly diagnosed with hypertension during a physical exam he recently took due to a change in his company’s health and wellness policy
PAST Medical history (PMH)
No serious illness
No surgeries
Health Maintenance
Last eye exam 8 yrs ago
Has never had a colonoscopy.
Medications
Multivitamin: 1 daily
Allergies
No known allergies
Social History
He has been married for 18 yrs to Monica, who is 8 yrs. his junior. They have 3 children, a son Mark 15, a daughter Kelly 12, and another daughter Andrea, 8. He has been employed as a sales representative for 10 yrs with the same company. It is a high pressure position, and he is expected to meet his sales quota each month (Stress Management). He is Catholic, but the family only attends services on religious holidays (Spiritual Guidance). He enjoys fishing, has a new boat he purchased 2 yrs. Ago but has only used twice. He helps to financially support his aging parents, and his wife provides them transportation to and from appointments and helps them with grocery shopping. He takes care of their bills for them due to his father’s failing vision (Caregiver Burnout).
He completed 2 yrs of college and earned an associate’s degree in business. He has always wanted to complete a Bachelor’s degree, but has not due to his work and family responsibilities(Suggest Caregiver Help). He learns best by reading the material; he does not absorb verbal information easily. He has always that “information has to be useful to bother learning it”(Design a Learning plan based on visual learning).
Tobacco use –Never
ETOH- Occasional on weekends
Immunizations & Travel
No recent travel
Received all childhood immunizations
Has not had a tetanus booster for 12 years (Needs
Name
Larry Garcia
Date
Gender
M
Allergies
DOB
12/21/1965
Age
45
Chief Compaint (CC)
“I feel fine, but they tell me my blood pressure is too high.”
History of Present illness (HPI)
Newly diagnosed with hypertension during a physical exam he recently took due to a change in his company’s health and wellness policy
PAST Medical history (PMH)
No serious illness
No surgeries
Health Maintenance
Last eye exam 8 yrs ago
Has never had a colonoscopy.
Medications
Multivitamin: 1 daily
Allergies
No known allergies
Social History
He has been married for 18 yrs to Monica, who is 8 yrs. his junior. They have 3 children, a son Mark 15, a daughter Kelly 12, and another daughter Andrea, 8. He has been employed as a sales representative for 10 yrs with the same company. It is a high pressure position, and he is expected to meet his sales quota each month (Stress Management). He is Catholic, but the family only attends services on religious holidays (Spiritual Guidance). He enjoys fishing, has a new boat he purchased 2 yrs. Ago but has only used twice. He helps to financially support his aging parents, and his wife provides them transportation to and from appointments and helps them with grocery shopping. He takes care of their bills for them due to his father’s failing vision (Caregiver Burnout).
He completed 2 yrs of college and earned an associate’s degree in business. He has always wanted to complete a Bachelor’s degree, but has not due to his work and family responsibilities(Suggest Caregiver Help). He learns best by reading the material; he does not absorb verbal information easily. He has always that “information has to be useful to bother learning it”(Design a Learning plan based on visual learning).
Tobacco use –Never
ETOH- Occasional on weekends
Immunizations & Travel
No recent travel
Received all childhood immunizations
Has not had a tetanus booster for 12 years (Needs