Ken Fowler iHuman soap note

Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan

SOAP Week 7: Evaluation and Management of GU/GI Conditions

Patient Information

Name: Ken Fowler

Age: 70 years

Sex: Male

Subjective

CC (chief complaint): Nausea and vomiting

HPI: the patient is a 70 year old who presented for further evaluation of his creatinine levels at the ED from his PCPs referral. He reports nausea and vomiting for 24 hours. The vomitus is clear with residual food particles. It is worsens with meals but reports no relieving factors. It is associated with symptoms of decreased urine output, decreased oral intake/poor appetite, and fatigue. The patient associates the onset of symptoms to intake of naproxen for lower back pain one week prior when he lifted something heavyKen Fowler i Human soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan.

Current meds:

  • Lisinopril
  • HCTZ
  • Metroprolol

Allergies: None

Vaccinations: Up to date with all the immunizations

Pertinent PMHx: patient is a known hypertensive on medications. He also reports mild chronic renal disease with microalbuminuria (400mg) and creatinine of 1.1.

Social hx: Ken Fowler admits to drinking a glass of wine with dinner frequently  either once or twice  weekly.

Fam Hx:

Questions:

  • What is your name?
  • Where are you?
  • What time is it?
  • What happened?
  • How can I help you today?
  • Have you had nausea and vomiting like this before?
  • What does your vomit look like?
  • Has there been any change in your nausea and/or vomiting over time?
  • Have you been vomiting anything that looks like blood or coffee grounds?
  • Do you have any pain or other symptoms associated with your nausea and/or vomiting?
  • Does anything make your nausea and/or vomiting better or worse?
  • How severe is your nausea and/or vomiting?
  • Have you lost weight?
  • Do you have any pain in your abdomen?
  • Do you have frothy urine?
  • Do you have any other symptoms or concerns we should discuss?
  • Can you tell me about any current or past medical problems you have had?
  • Are you taking any over-the-counter herbal medications?
  • Do you have any allergies?
  • Are you taking any prescription medications?
  • Do you drink alcohol? If so, what do you drink and how many drinks per day?

ROS

General: the patient appears in the ED independently. He denies recent fever, chills, worsening cough, sore throat.  He reports nausea, vomiting and decreased appetite Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan.

Integumentary/Skin: patient denies problems with an itchy scalp, skin changes,  moles, thinning  hair or brittle nails

Cardiovascular/Peripheral Vascular: the patient denies experiencing chest pain/pressure, exertion, chest discomfort, palpitations, decreased exercise tolerance, cold/blue fingers and toes.

Respiratory: the patient denies experiencing shortness of breath, difficulty catching breath, wheezing, chronic cough, or sputum production.

Gastrointestinal: patient reports nausea and vomiting, decreased oral intake, he denies diarrhea, constipation, bright red/dark tarry stools with bowel movements, bloating or early satiety

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 any muscle pains, joint pains, swelling, redness, joint stiffness, redness, and muscle cramps

Psychiatric: patient denies any problems with depression, nervousness, sadness, lack of interest, or changes in mood

Neurologic: the patient denies problems with dizziness, fainting, spinning room, seizures, weakness, numbness, and tremor or tingling

Endocrine: the patient denies problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite

Hematologic/lymphatic: the patient denies any bruising, bleeding gums, or nose bleeds.

Allergic/immunologic: the patient denies allergies to medication, food or environmental Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan.

Physical Exam

General:  Patient is A&O x4

VS: BP- 108/62 HR-98 (apical), RR-17, O2 sat-99% RA

General Appearance: the patient is A&Ox4. He appears to be overall healthy and in no distress

HEENT: Eyes: PERRLA, no conjunctivae-rim pallor. Examination with an ophthalmoscope reveals a bilateral red reflex, and sharp optic disks. Nose/Mouth/Throat: mucous membranes are dry

Cardiovascular/Peripheral Vascular: the patient has normal heart sounds S1, S2; there are no rubs, gallops, or murmurs.  PMI slight lateral and downward displaced

Respiratory: on inspection, the chest moves symmetrically with respiration, there are no scars, the lungs are clear in all lobes bilaterally, and there are no abnormal breath sounds auscultated (wheezing, crackles, rales or rhonchi).

Gastrointestinal: the abdomen is soft non-distended and non-tender. Bowel sounds present in all quadrants with auscultation. There are no masses or lumps or protruding tumors felt with palpation and percussion.  There is no CVA tenderness but there is mild periumbilical tenderness in superficial palpation. No renal, abdominal, or femoral bruits.

Musculoskeletal/Peripheral Vascular: no edema in upper or lower extremities. Muscle strength is 5/5 in all groups.

Neurologic:  A&O x4 to person, place, time and situation. MMSE

Integumentary/Skin:  the skin is dry and warm; there is no jaundice, pallor, scaling, ulceration, or rash.  Blanche time is 3-4 seconds suggesting dehydration.

Genitourinary: normal external genitalia, no urethral discharge, no tenderness or masses

Test Ordered and Diagnostic Results

  • Complete Blood Count
  • Renal Ultrasound
  • Urinalysis
  • Basic Metabolic Panel
  • Sodium (Na+), urine
  • Eosinophils urine
  • Pelvic Ultrasound

List the Differential Diagnosis You Identified In Ihuman

  1. Medication-Related (Side Effect)
  2. Uremia (intrarenal azotemia)
  3. Uremia (prerenal azotemia)
  4. Urinary Obstruction

List your primary dx with ICD code. Briefly explain/ discuss your primary dx and the rational

  • Uremia-prerenal azotemia (Acute Kidney Failure, Unspecified N17.9)- this patient  Presented with a history of a sudden onset increment in   levels of creatinine.  He also reported   a decreased oral intake, nausea and vomiting, and fatigue. One week earlier, he reportedly self-medicated with naproxen, a drug that is highly nephrotoxic for lower back pain. These are signs and symptoms of Acute Kidney Injury and the intake of naproxen plays a major role as a precursor of the symptoms (Levey & James, 2017). The fact that he is hypertensive and on both ACEs and a diuretic,   he is at a higher risk of volume depletion, a state that is also a risk factor for AKI. Besides, the physical exam findings of tachycardia, hypotension, dehydration, and   periumbilical tenderness support AKI as the most appropriate diagnosis Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan.

List the Differential Dx with ICD and A Brief Explanation the Rational

  1. ICD 10 995A Medication-Related (Side Effect)-the patient has a history of prior intake of naproxen, an NSAID. Naproxen inhibits COX enzymes reducing the synthesis of prostaglandins and this can result in renal ischemia, decrease pressure in the glomeruli and ultimately the setting of AKI.  Considering that he was also on ACE inhibitors and a diuretic, collectively, these factors increase the risks of AKI (Whiting et al., 2017).
  2. ICD 10 N00.9 Acute Nephritic Syndrome (Uremia- Intrarenal azotemia) – it includes intrinsic kidney pathologies such as glomerulopathies or renal failure. Apart from having elevated creatinine levels, patients may report nausea and vomiting, fatigue, oliguria, anorexia, and periumbilical pain. However, since there is no history to suggest an underlying systemic illness or more recent infection, this is less likely. To add on, on physical exam, the lack of findings such as periorbital and pedal edema which are primary features of potential causes intrarenal azotemia for conditions such as nephritic syndrome decreases the likelihood of this as the primary diagnosis (Hashmi & Pandey, 2020).
  3. ICD 10 9 Urinary Obstruction- the signs and symptoms of urinary obstruction which are similar to those that Ken Fowler presented with include; oliguria, delayed urination and abdominal pain. Besides Ken Fowlers age, a history of reduced urine output and hypertension are potential risk factors for obstruction.

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 physician/specialist for further evaluation and management of  renal disease to prevent  worsening outcomes
  • Nursing Orders:
    • IV Rehydration to correct dehydration and prevent the azotemia from worsening. Use IV saline until when the patient’s intravascular volume returns to normal.
  • Medication/intervention: dose, route, time
    • Discontinue the patient’s NSAIDs
    • Hold the patient’s HCTZ
    • Hold the patient’s Lisinopril
  • LABS: none
  • Ancillary orders: insert Foleys catheter to monitor input-output
  • Supportive services: consider maintaining patient on a DASH diet. And consult with a dietician on the best dietary approaches for a patient with mild chronic renal disease.
  • Patient education: educate the patient on the dangers of self-medication and  effects to the body (naproxen), educate on  hypertension and current drugs used for management, educate on medication adherence
  • Follow up or disposition: to return back immediately incase a new onset or similar symptoms begin. To return for follow up in two weeks to assess for progress including renal function Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan.
  • Health maintenance and Preventive health: none

Also Read: i-human case study answers

References

Hashmi, M. S., & Pandey, J. (2020). Nephritic Syndrome. StatPearls [Internet].

Levey, A. S., & James, M. T. (2017). Acute kidney injury. Annals of internal medicine, 167(9), ITC66-ITC80.

Whiting, P., Morden, A., Tomlinson, L. A., Caskey, F., Blakeman, T., Tomson, C., & Horwood, J. (2017). What are the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury? A systematic review and meta-analysis. BMJ open, 7(4).