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

Ken Fowler iHuman SOAP Note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan

Patient Information:

Name: Ken Fowler
Age: 70 years
Sex: Male

Subjective:

Chief Complaint (CC): Nausea and vomiting

History of Present Illness (HPI): Mr. Fowler is a 70-year-old man who came to the emergency department after a referral from his primary care provider. He complains of nausea and vomiting that has persisted for 24 hours. The vomit is clear with some food particles in it. He notes that his symptoms worsen after meals and are not relieved by anything. He also mentions decreased urine output, reduced oral intake, lack of appetite, and fatigue. Mr. Fowler associates the start of his symptoms with taking naproxen for lower back pain a week ago when he lifted a heavy object.

Current Medications:
– Lisinopril
– HCTZ (Hydrochlorothiazide)
– Metoprolol

Allergies: None

Vaccinations: Up to date with all recommended immunizations

Pertinent Past Medical History (PMHx): Mr. Fowler has a history of hypertension and mild chronic renal disease with microalbuminuria (400mg) and a creatinine level of 1.1.

Social History: Mr. Fowler occasionally drinks a glass of wine with dinner, typically once or twice a week.

Family History: Not mentioned

Questions Asked to the Patient:
– Gathering information about his current condition
– Exploring the details of his nausea and vomiting, including appearance and changes over time
– Inquiring about the presence of blood or coffee-ground-like material in the vomit
– Asking about associated symptoms and any pain or discomfort
– Investigating factors that worsen or alleviate his nausea and vomiting
– Assessing the severity of his symptoms
– Inquiring about weight loss
– Checking for abdominal pain
– Asking about urine characteristics, including frothiness
– Discussing any other symptoms or concerns
– Gathering details about past and current medical problems, over-the-counter and prescription medications, allergies, and alcohol consumption

Review of Systems (ROS):

General: Mr. Fowler appears in the emergency department independently. He denies fever, chills, cough, sore throat, and other respiratory symptoms. He reports nausea, vomiting, and decreased appetite.

Integumentary/Skin: He denies any issues with an itchy scalp, skin changes, moles, thinning hair, or brittle nails.

Cardiovascular/Peripheral Vascular: Mr. Fowler denies chest pain, exertion-related discomfort, palpitations, decreased exercise tolerance, or circulation problems in his extremities.

Respiratory: There are no complaints of shortness of breath, wheezing, chronic cough, or sputum production.

Gastrointestinal: Mr. Fowler reports nausea and vomiting, decreased oral intake, but denies diarrhea, constipation, blood in the stool, bloating, or early satiety.

Genitourinary: He denies pain, urinary issues, urgency, frequency, or incontinence but reports decreased urine output.

Musculoskeletal: There are no complaints of muscle or joint pain, swelling, redness, stiffness, or cramps.

Psychiatric: Mr. Fowler denies any issues with mood, such as depression, nervousness, sadness, or lack of interest.

Neurologic: There are no reported problems with dizziness, fainting, seizures, weakness, numbness, or tremors.

Endocrine: Mr. Fowler denies issues like intolerance to temperature, excessive thirst, sweating, frequent urination, or changes in appetite.

Hematologic/Lymphatic: There are no complaints of bruising, bleeding gums, or nosebleeds.

Allergic/Immunologic: Mr. Fowler has no known allergies to medication, food, or environmental factors.

Physical Examination:

General: Mr. Fowler is alert and oriented to person, place, time, and situation.

Vital Signs: Blood pressure: 108/62 mm Hg, Heart rate: 98 bpm (apical), Respiratory rate: 17 breaths per minute, O2 saturation: 99% on room air.

General Appearance: Mr. Fowler appears overall healthy and is not in distress.

HEENT (Head, Eyes, Ears, Nose, Throat): Pupils are equal, round, and reactive to light and accommodation (PERRLA). No pallor or redness of the conjunctivae is noted. Mucous membranes appear dry.

Cardiovascular/Peripheral Vascular: Heart sounds S1 and S2 are normal. No rubs, gallops, or murmurs are detected. The point of maximal impulse (PMI) is slightly laterally and downwardly displaced.

Respiratory: Chest movements are symmetrical with respiration, and lung sounds are clear in all lobes bilaterally. No abnormal breath sounds are auscultated.

Gastrointestinal: The abdomen is soft, non-distended, and non-tender. Bowel sounds are present in all quadrants. There are no palpable masses, lumps, or protruding tumors. Mild periumbilical tenderness is noted on superficial palpation. No renal, abdominal, or femoral bruits are detected.

Musculoskeletal/Peripheral Vascular: No edema is observed in the upper or lower extremities, and muscle strength is normal (5/5) in all groups.

Neurologic: Mr. Fowler is alert and oriented to person, place, time, and situation. His Mini-Mental State Examination (MMSE) is within normal limits.

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

Genitourinary: External genitalia appear normal, with no urethral discharge or tenderness.

Tests Ordered and Diagnostic Results:

– Complete Blood Count
– Renal Ultrasound
– Urinalysis
– Basic Metabolic Panel
– Urine Sodium (Na+)
– Urine Eosinophils
– Pelvic Ultrasound

Differential Diagnosis:

1. Medication-Related (Side Effect) – ICD 10: 995A
– Mr. Fowler’s history of naproxen use, an NSAID, can result in renal ischemia due to its inhibition of COX enzymes, reducing prostaglandin synthesis. This could lead to renal injury. The concurrent use of ACE inhibitors and a diuretic further increases the risk of acute kidney injury (AKI).

2. Uremia (Intrarenal Azotemia) – ICD 10: N00.9
– Elevated creatinine levels, nausea, vomiting, fatigue, and anorexia are characteristic of acute kidney injury (AKI). However, Mr. Fowler lacks the typical periorbital and pedal edema seen in nephritic syndrome, decreasing the likelihood of this diagnosis.

3. Urinary Obstruction – ICD 10: 9
– Oliguria, delayed urination, abdominal pain, and hypertension are symptoms associated with urinary obstruction. Mr. Fowler’s age and symptoms raise the possibility of this condition.

NURS 6003/NURS 6003A/NURS 6003F/NRSE 6003C/NURS 6003N/NURS 6003C: Transition to Graduate Study for Nursing

Primary Diagnosis:

Uremia (Prerenal Azotemia) – ICD 10: N17.9
– The sudden increase in creatinine levels, decreased oral intake, nausea,

vomiting, and fatigue are consistent with acute kidney injury (AKI). Mr. Fowler’s self-medication with naproxen for back pain is a significant factor in these symptoms. His hypertension and use of ACE inhibitors and a diuretic increase the risk of volume depletion, a known risk factor for AKI. Physical exam findings of tachycardia, hypotension, dehydration, and periumbilical tenderness support AKI as the primary diagnosis.

Differential Diagnosis (with ICD and Explanation):

1. Medication-Related (Side Effect) – ICD 10: 995A
– Mr. Fowler’s history of naproxen use, an NSAID, can result in renal ischemia due to its inhibition of COX enzymes, reducing prostaglandin synthesis. This could lead to renal injury. The concurrent use of ACE inhibitors and a diuretic further increases the risk of acute kidney injury (AKI).

2. Uremia (Intrarenal Azotemia) – ICD 10: N00.9
– Elevated creatinine levels, nausea, vomiting, fatigue, and anorexia are characteristic of acute kidney injury (AKI). However, Mr. Fowler lacks the typical periorbital and pedal edema seen in nephritic syndrome, decreasing the likelihood of this diagnosis.

3. Urinary Obstruction – ICD 10: 9
– Oliguria, delayed urination, abdominal pain, and hypertension are symptoms associated with urinary obstruction. Mr. Fowler’s age and symptoms raise the possibility of this condition.

Assessment/Plan:

– Admit to Medical-Surgical Unit
– Allergy: None
– Diet: Low sodium
– Activity: Mild physical activity, such as walking
– Consult/specialty services: Consultation with a renal physician/specialist for further evaluation and management of renal disease to prevent worsening outcomes
– Nursing Orders: IV rehydration with normal saline to correct dehydration and prevent worsening azotemia
– Medication/Intervention:
– Discontinue naproxen
– Hold HCTZ (Hydrochlorothiazide)
– Hold Lisinopril
– Ancillary Orders: Insert a Foley catheter to monitor input and output
– Supportive Services: Consider maintaining the patient on a Dietary Approaches to Stop Hypertension (DASH) diet and consult with a dietitian for dietary recommendations for mild chronic renal disease.
– Patient Education: Educate the patient on the risks of self-medication, the effects of naproxen on the body, hypertension management, and medication adherence.
– Follow-Up or Disposition: The patient should return immediately if new or similar symptoms occur and return for follow-up in two weeks to assess progress, including renal function.
– Health Maintenance and Preventive Health: Age-appropriate recommendations

Reference List:
1. Hashmi, M. S., & Pandey, J. (2020). Nephritic Syndrome. StatPearls [Internet].
2. Levey, A. S., & James, M. T. (2017). Acute kidney injury. Annals of internal medicine, 167(9), ITC66-ITC80.
3. 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).

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

Student’s Name

Institution

Course Code, Course Name

Instructor’s Name

Date

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

50. 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).
51. 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).
52. 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

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).

 

 To prepare:

Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with GI or GU conditions. 
Access i-Human from this week’s Learning Resources and review this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient. 
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis. 
Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. 
Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis. 
Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with GI or GU conditions. 
Assignment
As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.

Patient Information:

Subjective:

CC (chief complaint):

HPI:

Current meds:

Allergies:

Vaccinations: 

Pertinent PMHx:

Social hx:

Fam Hx:

Questions: Copy the questions you asked in ihuman here

ROS:

Physical Exam:

Test ordered and diagnostic results:

List the differential diagnosis you identified in ihuman 

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

List the differential Dx with ICD and a brief explanation the rational

Assessment/Plan:

Admit to: (ICU, Observation, med surge, etc)

Status: (critical ill, stable, guarded) 

CODE Status:

ALLERGY: 

Diet:

Activity:

Consult/ specialty services and rational:

Nursing orders: (iv, monitor, i/o etc..)
Medication/intervention: dose, route, time

LABS: (do not include labs already done)

Test: CT, CXR…etc (do not include labs already done)

Ancillary orders: pain management, sleeper, bowel program, PPI protection, DVT protection, PT/OT etc. 

Supportive services: There is more to being an NP than prescribing. Look at the supportive services required, PT/ OT, Dietary, REHAB, etc and make a referral. If in your opinion there is none, then state that.

Patient education: (include family if minors on disease, management and or drugs)

Follow up or disposition: Discharge planning. When coming back and why and to who?

Health maintenance and Preventive health: Age appropriate 

Reference list: Minimum 3 to support your treatment plan

Patient Information:

Subjective:

CC (chief complaint):

HPI:

Current meds:

Allergies:

Vaccinations:

Pertinent PMHx:

Social hx:

Fam Hx:

Questions: Copy the questions you asked in ihuman here

ROS:

Physical Exam:

Test ordered and diagnostic results:

List the differential diagnosis you identified in ihuman

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

List the differential Dx with ICD and a brief explanation the rational Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan

Assessment/Plan:

Admit to: (ICU, Observation, med surge, etc)

Status: (critical ill, stable, guarded)

CODE Status:

ALLERGY:

Diet:

Activity:

Consult/ specialty services and rational:

Nursing orders: (iv, monitor, i/o etc..)

Medication/intervention: dose, route, time

LABS: (do not include labs already done)

Test: CT, CXR…etc (do not include labs already done)

Ancillary orders: pain management, sleeper, bowel program, PPI protection, DVT protection, PT/OT etc.

Supportive services: There is more to being an NP than prescribing. Look at the supportive services required, PT/ OT, Dietary, REHAB, etc and make a referral. If in your opinion there is none, then state that.

Patient education: (include family if minors on disease, management and or drugs)

Follow up or disposition: Discharge planning. When coming back and why and to who?

Health maintenance and Preventive health: Age appropriate

Reference list: Minimum 3 to support your treatment plan Ken Fowler iHuman soap note – NURS 6531 Advanced Practice Care of Adults Across the Lifespan