Ken Fowler ihuman soap note
Ken Fowler ihuman soap note
Name: Ken Fowler_70 year-white male
Subjective
CC (chief complaint): Nausea and vomiting
HPI: Ken Fowler is a 70-year-old retired school teacher male who presents at the ED for evaluation of elevated creatinine having being referred by his PCP (Primary Care Provider) Prior before his visit to the PCP, Fowler experienced nausea and vomiting lasting 24 hours, which begun after taking a painkiller (naproxen) for lower back pain he experienced after hurting his back while carrying a boxes. The vomitus was clear with only residual food properties; it aggravated with meals and was relieved with decreased oral intake. As a result, for the past three days, he has not taken anything orally. The nausea and vomiting are associated extreme fatigue, decreased urinary output, and decreased oral intake. He gets pnueumovax and flu shot every year (UTD)is Risk factor advanced age naproxen an NSAID.
Fam HX: Father died at the age of 65, he had high cholesterol and heart disease. Mother had rheumatoid arthritis, but died from a stroke. Sister is in treatment for breast cancer.
Current medications: HCTZ, lisinopril, and metroprolol
Allergies: NKDA
Vaccinations: Up to date
PMHx: He is a hypertensive on HCTZ, lisinopril, and metroprolol. He also has a history of mild chronic renal disease creatinine 1.1 and microalbuminuria (400mg)
Social hx: He consumes a glass of wine with dinner either once or twice every week. Married no children.
ROS
General: Ken fowler presents for evaluation independently. He reports nausea and vomiting but denies chills, fevers, night sweats, or sore throats.
Cardiovascular/Peripheral Vascular: the patient denies palpitations, lower limb/upper limb edema, facial edema, chest pains/pressure, SOB, cold/blue fingers
Respiratory: the patient denies cough, wheezing, SOB, DIB
Gastrointestinal: patient acknowledges nausea, vomiting, and decreased appetite. He however denies constipation, diarrhea, or change in stool color.
Genitourinary: patient denies any pain, burning, dribbling, difficulty starting or stopping, urgency, frequency, or incontinence with urination. He reports decreased urine output
Musculoskeletal: the patient denies back pain, muscle and joint pain/swelling, and joint stiffness
Psychiatric: the patient denies feeling sad, depressed, mood changes, lack of interest and nervousness.
Neurologic: the patient denies tremors, numbness, tingling, weakness, fainting, or dizziness.
Endocrine: the patient denies increased sweating, increased thirst, he reports decreased appetite, but denies cold/heat intolerance.
Hematologic/lymphatic: the patient denies easy bleeding or bruising, bleeding from gums or nosebleeds.
Allergic/immunologic: the patient denies environmental, food, or drug allergies.
Physical Exam
General: Patient is A&O x4, in no acute pain or respiratory distress
VS: BP- 108/62 HR-98 (apical), RR-17, O2 sat-99% LA
HEENT: Eyes: PERRLA, there is no conjunctival pallor. Ear: no discharge, sharp optic disks, bilateral red reflex, Nose/Mouth/Throat: mucous membranes are dry
Cardiovascular/Peripheral Vascular: normal S1, S2 heard, no gallops, rubs, or murmurs. PMI slightly displaced downwards and laterally
Respiratory: the chest moves symmetrically, bilaterally clear lungs, and bronchial breath sounds auscultated no crackles, wheezes, or rhonchi.
Gastrointestinal: soft and non-distended, bowel sounds present in all four abdominal quadrants no palpated masses or lumps, there is mild periumbilical tenderness Musculoskeletal/Peripheral Vascular: no lower or upper extremity edema, 5/5 muscle strength across all groups.
Neurologic: A&O x4 to person, place, time, and situation, MMSE 30/30, deep tendon reflexes
Integumentary/Skin: dry and warm skin, no pallor, jaundice, ulceration, or scaling, 3-4 seconds blanching time
Genitourinary: normal external genitalia, no urethral discharge, no tenderness, or masses
Test Ordered and Diagnostic Results
Renal Ultrasound
Complete Blood Count
Eosinophils urine
Sodium (Na+), urine
Basic Metabolic Panel
Urinalysis
Pelvic Ultrasound
List the Differential Diagnosis You Identified In Ihuman
Medication-Related (Side Effect)
Uremia (intrarenal azotemia)
Uremia (prerenal azotemia)
Urinary Obstruction
List your primary dx with ICD code. Briefly explain/ discuss your primary dx and the rational
Acute Kidney Failure, Unspecified (N17.9) (Uremia-prerenal azotemia) – Ken Fowler
presented with complaints of elevated creatinine, nausea, and vomiting following an intake of naproxen, an NSAID. The nausea and vomiting were associated with fatigue, reduced oral intake, and decreased appetite. The sequence of occurrence of these events indicates that the most likely diagnosis would primarily be acute kidney injury with the drug naproxen as the primary causative factor. Naproxen is highly nephrotoxic and is a pre-renal cause of kidney failure (Hoste et al., 2018). The physical exam findings of an elevated heart rate, dehydration, tenderness at the periumbilical region, and hypotension also support this diagnosis.
List the Differential Dx with ICD and A Brief Explanation the Rational
Medication-Related Side Effect (ICD 10 995A) – Ken Fowler reports that prior to visiting his PCP, he experienced severe nausea, and vomiting that just preceded the intake of naproxen, an NSAID for Backpain. Naproxen acts by inhibiting COX enzymes to decrease prostaglandins synthesis, which can primarily result in renal ischemia, reduce glomeruli pressure, and increase the risk of acute kidney injury.
Acute Nephritic Syndrome (ICD 10 N00.9) – Patients with ANS will demonstrate high levels of creatinine, oliguria, fatigue, vomiting, and nausea, pain at the periumbilical region, and anorexia (Bhalla et al., 2019). It however follows a recent systemic illness, which lacks in the case of Ken Fowler. On physical exam, the clinician is likely to find pedal and facial edema, and periorbital edema.
Urinary Obstruction (ICD 10 9) – patients with urinary obstruction report symptoms such as; decreased urine output (oliguria), hesitancy, and abdominal pain. Ken Fowler ihuman soap note Its risk factors are: advanced age, a previous history of mild chronic renal disease, decreased urinary output, and underlying chronic diseases such as hypertension (Serlin, Heidelbaugh & Stoffel, 2018).
Assessment/Plan
Admit to: med-surge
Allergy: None
Diet: low-sodium
Activity: mild physical activity such as walking
Consult/ specialty services and rational: consult with a renal specialist
Nursing Orders:
IV Rehydration therapy with NS (normal saline) till the return of intravascular volume (Moore, Hsu & Liu, 2018).
Medication/intervention: dose, route, time
Hold the patient’s HCTZ and lisinopril
Discontinue the patient’s NSAIDs
LABS: none
Ancillary orders: insert Foleys catheter to monitor input-output
Supportive services: consult with a dietician on appropriate dietary forms for a patient with hypertension and mild chronic renal disease.
Patient education:
Next time do not self-medicate. Since you are taking drugs for high blood pressure, it is important to understand that drugs interact with each other. If you have to take any OTC drug, prescription drug, or herbal medication, you must first inform and obtain the consent of your PCP (Moore, Hsu & Liu, 2018).
Maintain a DASH diet and adhere to your hypertensive drug regimen for adequate blood pressure control as guided
Follow up or disposition:
return immediately when you experience similar symptoms or new onset of symptoms
follow up in 2 weeks post-discharge for evaluation of progress Ken Fowler ihuman soap note
Health maintenance and Preventive health: advice on the need to maintain upto date immunizations
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