I-human Note Template
I-human Note Template
Patient Information: Initials: K.F, Age: 70 YO, Sex: Male, Race: Caucasian
Subjective:
CC (chief complaint);Nausea and Vomiting
HPI: Mr. Fowler it’s a 7-year-old Caucasian male who is sent to the Ed by his primary care physician for further evaluation of a grinding of 3.2 mg/dL following a three-day history of nausea and vomiting now with dry hives, poor PO intake, fatigue, the crazy rain volume, and orthostatic hypotension (108/60) and tachycardia (98 bmp). PMH it’s significant for lifting a heavy object resulting in a low back pain one week prior. He self-medicated with NSAIDS (Naproxen) BID). his medications include lisinopril, metoprolol, and HCTZ. His PMH is also significant for mild chronic renal disease with a creatinine (one month ago) of 1.1 with 400 mg albuminuria. Physical exam is notable for dry mucous membranes, mild periumbilical tenderness, and lack of CVA tenderness or bladder distention
Current Medications: Naproxen, Lisinopril, Metoprolol, Hydrochlorothiazide
Allergies: NKA
Pertinent PMHx: Hypertension, tonsillectomy out as a kid, appendectomy, 35 years ago now, back pain, kidney injury . Include immunization status. Is the patient missing any vaccinations? Do not use “UTD or not missing any vaccinations.”
Soc Hx: Patient verbalized drinking Alcohol drinking a glass of wine with dinner frequently once or twice per week, but I haven’t done that for over a week now . Denies any tobacco or illicit drug use
Fam Hx: No known family history.
History questions asked: List out each question you asked the patient/parent. This is a focused exam unless a school or yearly physical:
1. How can I help you today?
2. Do you have any other symptoms or concerns we should discuss?
3. When did your nausea and vomiting start?
4. Have you had nausea and/or vomiting like this before? Ans: No I just don’t feel well.
5. How severe is your nausea and/or vomiting? Ans: I’ve not eaten much of anything in the last 3 days, so I am not sure how to answer that question. Vomiting is a miserable business so for me it is bad.
6. Has there been any change in your nausea and vomiting overtime? Ans: When this started, I was vomiting a couple times a day. I no longer have anything in my stomach to vomit—so it is just dry heaves.
7. Have you been vomiting anything that looks like blood or coffee grounds? Ans: No, that will be horrible.
8. Do you have any pain or other symptoms associated with your nausea or vomiting? ANS: I pulled my back last week lifting a box out of my basement. The pain is finally getting better. But that doesn’t have anything to do with my vomiting. Oh, I have been getting lightheaded if I stand up too.
9. Do you have any pain in your abdomen? ANS: I don’t really have belly pain, but my stomach muscles seem a bit sore probably from all the vomiting I’ve been doing.
10. Does anything make your nausea and/or vomiting better or worse? ANS: It does get worse when I eat, that’s why I haven’t eaten much.
11. What does your vomit look like? ANS: Clear or residual food particles, but I haven’t eaten for over 24 hours.
12. Do you have frothy urine? ANS; Not that I’ve noticed
13. Have you lost weight? ANS: I don’t really know.
14. Do you have allergies? ANS: NO
15. Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? ANS: Yes, I have already told you about my nausea and vomiting. But none of the other stuff. My poop is normal
16. When you urinate, have you noticed any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency? ANS: Uh, no. In fact, I am barely peeing at all.
17. Are you taking any prescription medications? ANS: I take lisinopril, metoprolol, hydrochlorothiazide for blood pressure. I haven’t taken anything for the last 24 hours because I feel so sick, can’t keep the pills.
18. Are you taking any over the counter or herbal medications? ANS: I am not taking anything now, but when I strained my back, I started taking Naproxen. I guess that was about 7-10 days ago. I took a couple pills twice a day. It really helped the pain. Do you think they screwed up my stomach and that is why I have so much nausea?
19. How severe (1-10 scale) is the pain in your back? ANS: My back doesn’t hurt that much anymore.
20. Can you tell me about any current or past medical problems? I have high blood pressure. I take medications for that. I was told last month my blood pressure has caused some kidney damage. Something about my protein in my urine. Oh, about a week ago I pulled my back lifting a heavy carton when I was cleaning out my garage. It was painful, so I took something for the pain. My back is really pretty good right now, but then this nausea vomiting began
21. Any previous medical, surgical, or dental procedures? ANS: Yes I had my tonsils out as a kid and then my appendix out about 35 years ago now.
22. Have you been hospitalized for symptoms like the ones you have now? ANS: No
23. What childhood illnesses have you had? ANS: The usual coughs, colds, and tummy aches. Nothing remarkable.
24. Are you up to date with your immunizations? ANS: I have a pneumovax and flu shot every year.
25. Do you now or have you ever smoked or chewed tobacco? ANS: I’ve never smoked.
26. Do you drink alcohol? If so, what do you drink and how many drinks per day? ANS: I drink a glass of wine with dinner frequently once or twice per week, but I haven’t done that for over a week now.
27. Have you had any contact with other sick people? ANS: No
28. Do you have any problems with fatigue, difficulty sleeping, or intentional weight loss or gain, fevers, or night sweats? ANS: Yeah, I feel exhausted, but I think it is because of my nausea… just keeps me up at night. No fevers
29. Is anyone in your family also suffering with nausea and/or vomiting? ANS: Nope
30. Tell me about your job? ANS: I am a retired teacher. I taught social studies.
31. Do you have medical insurance? Yes
32. Are you sexually active? No
33. Can you tell me about your diet? What do you normally eat? ANS: Seems fine to me.
34. ) Do you have any problems with headaches that don’t go away with aspirin or Tylenol, double blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throat, or difficulty swallowing? Nope
35. Do you experience chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting angry, palpitations, decrease exercise tolerance, or blue/cold fingers and toes? Not at all. But I am not worried about my heart or anything should I be?
36. ) Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production? No
37. Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, nick or shoulder pain, or hip pain? Nope
38. ) Have you noticed any bruising, bleeding gums, nosebleeds, or other sites of increase bleeding? No.
39. Do you have problems with heat or cold intolerance, increased thirst, increase sweating, frequent urination, or change in appetite? I feel a bit thirsty, but the nausea keeps me from drinking because I am afraid all I will do is vomit it up back up. I just hate vomiting.
40. Do you have any problems with, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? No this is, but I am a bit lightheaded when I stand up and when I feel weak and exhausted. Not tingling or numbness or actually passing out.
41. Do you have problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or seen things that you know are not there? Before getting sick, no.
42. Do you have any problems with an itchy scalp, skin changes, moles, thinning hair or brittle nails? ANS: Uh..no
43. What is your name? Ken Fowler
44. Where are you? In the Emergency Room
45. What time is it? Around 6:10am
46. What happened? ANS Not sure what you want to know. I think I told you about my PCP telling me to come in because of the lab results.
ROS: GENERAL: No general body weakness. Fever and chills are absent.
HEENT: No history of headaches. Thyroid palpable but not enlarged. No visual loss or blurred vision, pinkish conjunctiva, and whitish sclera. Pupils equal, round, and normal reaction to light. No hearing impairment was detected. There is no nasal congestion, swelling, or sneezing. No difficulty during swallowing or sore throat was reported, dry mucous membrane
SKIN: Skin is warm and dry, no pallor, Jaundice, rash, scaling or ulceration.
CARDIOVASCULAR: No chest pain or discomfort was reported. No history of heart murmurs or palpitations. No swelling or edema was noted. Increased blood pressure readings. The PMI of the patient has slight laterally displacement.
RESPIRATORY: No shortness of breath or cough was noted. No difficulty in breathing on exertion and production of sputum absent.
GASTROINTESTINAL: No reports of nausea and vomiting. No diarrhea or blood in the stool. Abdomen is soft, non-distended, mild tenderness noted in periumbilical region, more superficial, normal to percussion no tympany. Shifting dullness or percussive evidence of hepatosplenomegaly
NEUROLOGICAL: The patient has complaints of headaches
MUSCULOSKELETAL: Test strength, no proximal weakness, normal symmetrical strength.
Visual proximal muscle weakness, normal symmetrical strength.
Objective:
Vital Signs:
Height: 5’10
BMI:27.3
Wt:190llbs (86.0kg)
Blood pressure: 108/60
Pulse:98
Temperature: 99.9F
Respiration: 18
SP02: 98%
Physical exam:
General: Pt. appears well groomed, fatigued
HEENT: Normocephalic, Conjunctiva pink, no exudate noted, bilateral TMs, Erythematous, dull, nares normal, pink and dry mucosa, no polyps, no discharge, no cervical or pre-post auricular lymphadenopathy.
Cardiovascular: No chest pain or discomfort was reported. No history of heart murmurs or palpitations. No swelling or edema was noted. Increased blood pressure readings. The PMI of the patient has slight laterally displacement
Respiratory: No shortness of breath or cough was noted. No difficulty in breathing on exertion and production of sputum absent.
GI: No reports of nausea and vomiting. No diarrhea or blood in the stool. Abdomen is soft, non-distended, mild tenderness noted in periumbilical region, more superficial, normal to percussion no tympany. Shifting dullness or percussive evidence of hepatosplenomegaly
Neuro: Headaches to rule out HTN commonly appear in early mornings and are a dull, back of the head type of pain.
Diagnostic results:
BMP ̵ Renal US ̵ Sodium Urine ̵ Urinalysis ̵ CBC , Eosinophils, urine ̵ Pelvic US
Assessment:
1. Uremia (prerenal azotemia) (Main Diagnosis)
2. Medication related (side-effect)
3. Urinary obstruction
4. Uremia (Intrarenal):
Differential Diagnoses Primary Diagnosis and ICD-10 code: Also include any procedural codes. 3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
Plan?
Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?
Therapeutic modalities: pharmacological and nonpharmacological management. Give specific medications, dosing, and duration. Include anticipated therapeutic modalities/symptomatic treatment for patients if they are sent to ED or directly admitted.
Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening. What immunizations do they need?
Patient education: Explanations and advice given to patient and family members.
Disposition/follow-up instructions: include when to follow up in clinic, follow up sooner, or go to ER. When should they be seen by a specialist or therapist?
References
Minimum of 3 timely, scholarly references, that proves this plan and follows current standards of care. The course text may NOT be used as a reference. The references must be professional and not general patient education websites.
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