Posted: January 8th, 2023
Ken Fowler ihuman soap note
Name: Ken Fowler
Age: 70 years
CC (chief complaint): Nausea and vomiting
HPI: Ken Fowler is a 70-year-old male who presents at the ED for evaluation of elevated creatinine having being referred by his PCP (Primary Care Provider) Ken Fowler ihuman soap note. 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 load. 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.
Current medications: HCTZ, lisinopril, and metroprolol
Vaccinations: Up to date
Pertinent PMHx: He is a hypertensive on HCTZ, lisinopril, and metroprolol. H is also on follow-up, he has a history of mild chronic renal disease creatinine 1.1 and microalbuminuria (400mg) Ken Fowler ihuman soap note
Social hx: He consumes a glass of wine with dinner either once or twice every week.
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. Ken Fowler ihuman soap note
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.
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
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
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 Ken Fowler ihuman soap note.
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