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iHuman SOAP Note / Emergency Department
Ken Fowler — Clinical Case
Patient NameKen FowlerAge70 YearsSexMaleChief ComplaintNausea & VomitingAllergiesNKDASettingEmergency DepartmentSSubjective
Chief Complaint (CC)Nausea and vomitingHistory of Present Illness (HPI)Ken Fowler is a 70-year-old male who presents to the ED for evaluation of elevated creatinine, having been referred by his Primary Care Provider (PCP). Prior to that PCP visit, Mr. Fowler experienced nausea and vomiting lasting 24 hours, which began after taking naproxen (an NSAID) for lower back pain sustained while carrying a load. The vomitus was clear with only residual food properties; it was aggravated by meals and relieved by decreased oral intake. For the three days preceding this presentation, he has taken nothing by mouth. The nausea and vomiting are associated with extreme fatigue, decreased urinary output, and significantly reduced oral intake.Current MedicationsHCTZ | Lisinopril | MetoprololOTC / HerbalNaproxen (self-administered for back pain — precipitating factor)AllergiesNo known drug, food, or environmental allergiesVaccinationsUp to datePertinent PMHxHypertension (on HCTZ, lisinopril, metoprolol); mild chronic renal disease — creatinine 1.1; microalbuminuria (400 mg)Social HistoryConsumes one glass of wine with dinner once or twice per week. No tobacco or illicit drug use reported.Interview 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?
SReview of Systems (ROS)
General+ Nausea, vomiting
− Chills, fevers, night sweats, sore throatCardiovascular / PVS− Palpitations, edema (upper/lower/facial), chest pain, SOB, cold/blue fingers
Respiratory− Cough, wheezing, SOB, DIB
Gastrointestinal+ Nausea, vomiting, decreased appetite
− Constipation, diarrhea, change in stool colorGenitourinary+ Decreased urine output
− Pain, burning, urgency, frequency, incontinenceMusculoskeletal− Back pain, muscle/joint pain or swelling, joint stiffness
Psychiatric− Sadness, depression, mood changes, lack of interest, nervousness
Neurologic− Tremors, numbness, tingling, weakness, fainting, dizziness
Endocrine+ Decreased appetite
− Increased sweating, increased thirst, cold/heat intoleranceHematologic / Lymphatic− Easy bleeding/bruising, bleeding gums or nosebleeds
Allergic / Immunologic− Environmental, food, or drug allergies
OObjective
Vital SignsBP108/62HR (Apical)98 bpmRR17O₂ Sat99% (LA)Note: Hypotension and tachycardia consistent with volume depletion / prerenal pathology.
Physical Examination FindingsPatient is alert and oriented ×4, in no acute pain or respiratory distress.Eyes: PERRLA, no conjunctival pallor. Ears: no discharge, sharp optic discs, bilateral red reflex. Nose/Mouth/Throat: mucous membranes are dry.Soft and non-distended. Bowel sounds present in all four quadrants. No palpable masses or lumps. Mild periumbilical tenderness noted.Tests Ordered & DiagnosticsRenal UltrasoundComplete Blood Count (CBC)Urine EosinophilsUrine Sodium (Na+)Basic Metabolic Panel (BMP)Urinalysis (UA)Pelvic UltrasoundAAssessment
Primary DiagnosisPrimary Diagnosis · ICD-10: N17.9Acute Kidney Failure, Unspecified — Prerenal Azotemia (Uremia)Ken Fowler presented with elevated creatinine, nausea, and vomiting following self-administration of naproxen, an NSAID, for back pain. The nausea and vomiting were accompanied by extreme fatigue, significantly reduced oral intake, and decreased urine output. The chronological sequence of events — back injury, naproxen use, GI symptoms, oliguria, and referral for elevated creatinine — points to acute kidney injury with naproxen as the primary causative agent. NSAIDs such as naproxen are nephrotoxic through COX inhibition, which reduces prostaglandin-mediated afferent arteriolar dilation, thereby decreasing glomerular filtration pressure and precipitating prerenal acute kidney injury (Hoste et al., 2018). Physical exam findings of hypotension (108/62), tachycardia (HR 98), dry mucous membranes, prolonged blanching time, and periumbilical tenderness collectively corroborate a prerenal etiology secondary to volume depletion and NSAID nephrotoxicity.
Differential DiagnosesMedication-Related Side EffectICD-10: 995AMr. Fowler reports that nausea and vomiting followed his self-initiated naproxen use for back pain. Naproxen inhibits COX-1 and COX-2 enzymes, reducing prostaglandin synthesis. This reduction causes renal ischemia, decreased glomerular pressure, and heightened risk of acute kidney injury, particularly in a patient with pre-existing mild chronic renal disease and hypertension.
Acute Nephritic SyndromeICD-10: N00.9Patients with acute nephritic syndrome may present with elevated creatinine, oliguria, fatigue, nausea, vomiting, periumbilical tenderness, and anorexia (Bhalla et al., 2019). However, this diagnosis typically follows a recent systemic illness, which Mr. Fowler does not report. Additionally, pedal edema, facial edema, and periorbital edema — common in nephritic syndrome — are absent on physical examination, making this a less likely diagnosis.
Urinary ObstructionICD-10: N13.9Patients with urinary obstruction commonly report decreased urine output (oliguria), hesitancy, and abdominal pain. Mr. Fowler’s advanced age, history of mild chronic renal disease, and underlying hypertension are recognized risk factors. However, he denies hesitancy, dribbling, or difficulty initiating or stopping urination, and no urethral or bladder pathology was identified on exam, reducing the clinical probability of this diagnosis (Serlin, Heidelbaugh & Stoffel, 2018).
PPlan
Admission DetailsAdmit ToMedical-Surgical UnitAllergiesNone / NKDADietLow-sodium dietActivityMild physical activity (e.g., ambulation / walking)ConsultsRenal specialist (nephrology consultation)Nursing Orders- Initiate IV rehydration therapy with normal saline (NS) until restoration of adequate intravascular volume (Moore, Hsu & Liu, 2018).
- Hold HCTZ and lisinopril — both medications are contraindicated in the setting of acute dehydration and prerenal AKI.
- Discontinue NSAIDs (naproxen) immediately — primary nephrotoxic agent.
- Insert Foley catheter to accurately monitor urine input/output.
- Consult dietitian regarding appropriate dietary planning for a patient with concurrent hypertension and mild chronic renal disease.
Medications / InterventionsNo new pharmacologic agents initiated at this time. Management is primarily supportive: IV fluid resuscitation, removal of nephrotoxic agents, and hemodynamic monitoring. Reassess renal function post-rehydration before resuming any antihypertensives.Laboratory OrdersSerial BMP monitoring to track creatinine trends, electrolyte balance, and BUN levels. Repeat urinalysis as clinically indicated. Monitor urine output hourly via Foley.Patient Education- Avoid self-medicating with OTC drugs, especially NSAIDs. Because you take medications for high blood pressure, drug interactions are a real concern. Always consult your PCP before starting any OTC, prescription, or herbal medication (Moore, Hsu & Liu, 2018).
- Maintain a DASH diet and adhere consistently to your antihypertensive medication regimen for adequate blood pressure control.
- Monitor your urine output at home — report any notable decreases or changes in color promptly to your provider.
- Ensure adequate daily fluid intake unless otherwise instructed by your care team, particularly during episodes of illness or reduced appetite.
Follow-Up / Disposition- Return immediately to the ED if similar symptoms recur or new symptoms develop.
- Follow-up appointment in 2 weeks post-discharge to evaluate renal function recovery and blood pressure control.
Health Maintenance & Preventive HealthAdvise patient to maintain up-to-date immunization schedule. Reinforce importance of regular preventive care visits given comorbidities of hypertension and chronic kidney disease stage II.REFReferences
- 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. https://doi.org/10.4103/jfmpc.jfmpc_404_18
- 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. https://doi.org/10.1038/s41581-018-0052-0
- 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. https://doi.org/10.1053/j.ajkd.2017.11.021
- 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. https://www.aafp.org/pubs/afp/issues/2018/1015/p496.html
Assignment Week:
Course: Advanced Health Assessment / NR509 or NR511 (or equivalent clinical reasoning course) Assignment Title: iHuman Clinical Reasoning Reflection — Care Planning and Patient Safety in Acute Kidney Injury
Overview / Description:
Building on the Ken Fowler iHuman encounter, this follow-up written assignment asks you to move beyond diagnosis into evidence-based clinical reasoning, interprofessional care coordination, and patient safety analysis. In a 900-to-1,200-word APA-formatted paper, reflect on and analyze the clinical decision-making process demonstrated in the Ken Fowler case, with a specific focus on how the patient’s medication history, comorbidities (hypertension and CKD stage II), and NSAID use collectively increased his risk for acute kidney injury. Your paper must identify at least two patient safety concerns relevant to this case, propose interprofessional interventions (including nephrology, nursing, pharmacy, and dietetics roles), and apply at least one evidence-based clinical practice guideline — such as the KDIGO AKI guidelines — to justify your management decisions. You are required to include a minimum of three peer-reviewed references published within the past five years, formatted in APA 7th edition with DOIs. This assignment is worth 20% of your total course grade and is due at the end of Week 6 via the course LMS submission portal.
Requirements at a Glance:
- 900–1,200 words, APA 7th edition format
- Minimum 3 peer-reviewed references (2020–2025), with DOIs
- Address: medication reconciliation, CKD risk stratification, NSAID contraindications, interprofessional roles, and KDIGO guideline application
- Submit as a Word document (.docx) through the LMS by 11:59 PM on the due date
