Ken Fowler’s iHuman Soap Note

Ken Fowler’s iHuman Soap Note

Patient Details

– Patient’s Name: Ken Fowler
– Age: 70 years
– Gender: Male

Subjective Information

Chief Complaint (CC): Ken Fowler is a 70-year-old male who came to the Emergency Department (ED) due to nausea and vomiting.

History of Present Illness (HPI): Mr. Fowler had been referred by his Primary Care Provider (PCP) after experiencing nausea and vomiting for 24 hours. This issue arose after he took a painkiller (naproxen) for lower back pain, which he got from carrying a heavy load. The vomit was clear with some residual food particles. It worsened after meals and improved with reduced oral intake. Consequently, he hasn’t eaten anything orally for the past three days. He also reports extreme fatigue, reduced urinary output, and decreased oral intake.

Current Medications: Mr. Fowler is currently taking HCTZ, lisinopril, and metoprolol.

Allergies: None

Vaccinations: Up to date

Pertinent Past Medical History: He has hypertension and is on medication for it. He also has a history of mild chronic renal disease with a creatinine level of 1.1 and microalbuminuria (400mg).

Social History: Mr. Fowler consumes a glass of wine with dinner once or twice a week.

Questions Asked:

– 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?

Alcohol Use Disorders; Rachel Adler Shadow Health – Subjective Data Collection

Review of Systems (ROS)

General: Mr. Fowler presents 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, shortness of breath, cold/blue fingers.

Respiratory: The patient denies cough, wheezing, shortness of breath, and difficulty in breathing.

Gastrointestinal: The patient acknowledges nausea, vomiting, and decreased appetite but denies constipation, diarrhea, or changes in stool color.

Genitourinary: The 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, and 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 Examination

General: Mr. Fowler is alert and oriented, not in acute pain, and not in respiratory distress.

Vital Signs: Blood Pressure – 108/62, Heart Rate – 98 (apical), Respiratory Rate – 17, Oxygen Saturation – 99%, Level of Alertness – Awake and Oriented x4 (person, place, time, situation), Mini-Mental State Examination (MMSE) – 30/30, Deep Tendon Reflexes – Normal.

HEENT: Eyes – PERRLA, no conjunctival pallor. Ears – No discharge, sharp optic disks. Nose/Mouth/Throat – Dry mucous membranes.

Cardiovascular/Peripheral Vascular: Normal heart sounds, no gallops, rubs, or murmurs. Point of Maximum Impulse (PMI) slightly displaced downwards and laterally.

Respiratory: Symmetrical chest movement, clear lung sounds, no crackles, wheezes, or rhonchi.

Gastrointestinal: Soft and non-distended abdomen, bowel sounds present in all four abdominal quadrants, no palpated masses or lumps, mild periumbilical tenderness.

Genitourinary: Normal external genitalia, no urethral discharge, no tenderness, or masses.

Tests Ordered and Diagnostic Results

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

Differential Diagnosis Identified in iHuman

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

Primary Diagnosis with ICD Code and Rationale

Primary Diagnosis: Acute Kidney Failure, Unspecified (N17.9) (Uremia-prerenal azotemia) – Mr. Fowler presented with elevated creatinine, nausea, and vomiting following the intake of naproxen, an NSAID. The sequence of events and physical exam findings support the diagnosis of acute kidney injury, primarily caused by naproxen’s nephrotoxicity.

Differential Diagnoses with ICD Codes and Explanations

1. Medication-Related Side Effect (ICD 10 995A) – Mr. Fowler’s symptoms occurred shortly after taking naproxen, an NSAID, which can lead to renal ischemia and acute kidney injury.

2. Acute Nephritic Syndrome (ICD 10 N00.9) – ANS typically follows a recent systemic illness, which is not the case with Mr. Fowler. It presents with symptoms such as high creatinine levels, oliguria, fatigue, vomiting, and nausea, along with physical exam findings like pedal and facial edema.

3. Urinary Obstruction (ICD 10 9) – This condition is characterized by decreased urine output, hesitancy, and abdominal pain. Mr. Fowler has risk factors such as advanced age and underlying chronic diseases like hypertension.

Assessment/Plan

– Admit to med-surge
– Allergy: None
– Diet: Low-sodium
– Activity: Mild physical activity, such as walking
– Consult/specialty services and rationale: Consult with a renal specialist
– Nursing Orders: IV rehydration therapy with normal saline until intravascular volume is restored.
– Medication/intervention: Hold the patient’s HCTZ and lisinopril, discontinue NSAIDs.
– LABS: None
– Ancillary orders: Insert Foley’s 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: Advise against self-medication, inform PCP about any OTC or prescription medication, maintain a DASH diet, and follow the hypertensive drug regimen.
– Follow up or disposition: Return immediately for similar symptoms or new symptoms, follow up in 2 weeks post-discharge for progress evaluation.
– Health maintenance and preventive health: Emphasize the importance of maintaining up-to-date immunizations.

References

Bhalla, K., Gupta, A., Nanda, S., & Mehra, S. (2019). Epidemiology and clinical outcomes of acute glomerulonephritis in a teaching hospital in North India. Journal of Family Medicine and Primary Care, 8(3), 934.

Hoste, E. A., Kellum, J. A., Selby, N. M., Zarbock, A., Palevsky, P. M., Bagshaw, S. M., & Chawla, L. S. (2018). Global epidemiology and outcomes of acute kidney injury. Nature Reviews Nephrology, 14(10), 607-625.

Moore, P. K., Hsu, R. K., & Liu, K. D. (2018). Management of acute kidney injury: core curriculum 2018. American Journal of Kidney Diseases, 72(1), 136-148.

Serlin, D. C., Heidelbaugh, J. J., & Stoffel, J. T. (2018). Urinary retention in adults: evaluation and initial management. American family physician, 98(8), 496-503.