Ken Fowler iHuman Assignment Help

Ken Fowler’s iHuman case study presents a 70-year-old male patient with complaints of nausea, vomiting, and fatigue, which developed after taking naproxen for lower back pain. This case is a critical learning tool for medical and nursing students, helping them understand the complexities of managing patients with multiple health concerns, including medication side effects, chronic disease, and acute conditions. In this article, we explore Ken Fowler iHuman case study in-depth, breaking down the key elements including the SOAP note (Subjective, Objective, Assessment, Plan), differential diagnoses, and the management plan.

Ken Fowler iHuman Problem Statement

Ken Fowler is a 70-year-old male who presents with elevated creatinine levels, nausea, vomiting, and extreme fatigue following his intake of naproxen for back pain. These symptoms are further complicated by his history of hypertension and mild chronic renal disease. The case study provides an excellent example of how non-steroidal anti-inflammatory drugs (NSAIDs) can adversely affect kidney function, especially in patients with pre-existing kidney conditions. The challenge lies in assessing the patient’s condition, determining the cause of acute kidney injury (AKI), and devising an appropriate management plan.

Ken Fowler iHuman Chief Complaint (CC)

The patient’s primary complaint is nausea and vomiting. These symptoms began after he took naproxen for back pain. He also reports decreased urinary output and extreme fatigue, which are concerning for potential kidney injury or other underlying medical conditions.

History of Present Illness (HPI)

Ken Fowler experienced nausea and vomiting that started 24 hours after taking naproxen. His vomitus was clear with residual food properties and worsened with meals, which led to a significant reduction in his oral intake for the past three days. The nausea and vomiting were accompanied by fatigue and decreased urinary output. He also experienced a notable decrease in oral intake due to his discomfort.

Ken’s history includes hypertension, for which he is currently taking HCTZ (hydrochlorothiazide), lisinopril, and metoprolol. He also has a history of mild chronic kidney disease, with previous creatinine levels of 1.1 mg/dL and microalbuminuria. He reports consuming wine once or twice a week but denies any drug allergies.

Ken Fowler iHuman Differential Diagnosis

Based on Ken Fowler’s symptoms, the following differential diagnoses are considered:

1. Acute Kidney Failure, Unspecified (N17.9) – The most likely diagnosis, given his elevated creatinine, nausea, vomiting, and decreased urine output, is acute kidney injury (AKI) secondary to NSAID use. Naproxen, like other NSAIDs, is nephrotoxic, particularly in patients with pre-existing kidney conditions.
2. Medication-Related Side Effect (ICD 10 995A) – Naproxen, an NSAID, can cause adverse effects such as gastrointestinal disturbances and nephrotoxicity. The patient’s nausea and vomiting, along with renal impairment, may be directly linked to his recent use of this medication.
3. Acute Nephritic Syndrome (ICD 10 N00.9) – Patients with acute nephritic syndrome (ANS) often present with elevated creatinine, oliguria (decreased urine output), fatigue, nausea, and vomiting. However, Ken Fowler does not have a history of recent systemic illness, making this diagnosis less likely.
4. Urinary Obstruction (ICD 10 N13.9) – While less likely, urinary obstruction can cause symptoms like decreased urine output and abdominal pain. Given the patient’s history of mild chronic renal disease, this is a possibility, although his physical exam findings do not suggest a urinary obstruction.

Ken Fowler iHuman SOAP Note

Patient Information

• Name: Ken Fowler
• Age: 70 years
• Sex: Male

Subjective

• Chief Complaint (CC): Nausea and vomiting.
• HPI: Ken Fowler presents at the emergency department for the evaluation of elevated creatinine levels after being referred by his primary care provider. Prior to this visit, he experienced nausea and vomiting for 24 hours after taking naproxen for back pain. He reports extreme fatigue, decreased urinary output, and reduced oral intake over the last three days.
• Current Medications: HCTZ, lisinopril, metoprolol.
• Allergies: None.
• Vaccinations: Up to date.
• Pertinent Past Medical History (PMHx): Hypertension, mild chronic renal disease (creatinine 1.1 mg/dL, microalbuminuria 400 mg).

Review of Systems (ROS)

• General: Reports fatigue, nausea, and vomiting; denies chills, fever, night sweats.
• Cardiovascular: Denies palpitations, chest pain, edema.
• Respiratory: Denies cough, shortness of breath.
• Gastrointestinal: Reports nausea, vomiting, decreased appetite; denies diarrhea or constipation.
• Genitourinary: Decreased urine output; denies dysuria or urinary frequency.
• Musculoskeletal: Denies joint pain, back pain.
• Neurological: Denies dizziness, weakness.
• Psychiatric: Denies depression or mood changes.

Objective

• Vital Signs (VS): Blood pressure 108/62 mmHg, heart rate 98 bpm, respiratory rate 17 breaths/min, O2 saturation 99%.
• Physical Examination:
  • General: Alert and oriented x4, no acute distress.
  • HEENT: Pupils equal, round, and reactive to light and accommodation (PERRLA), no conjunctival pallor, mucous membranes dry.
  • Cardiovascular: Normal heart sounds (S1, S2), no murmurs or gallops.
  • Respiratory: Clear lung sounds, symmetrical chest movement, no wheezing or crackles.
  • Gastrointestinal: Mild tenderness in the periumbilical region, bowel sounds present in all quadrants.
  • Musculoskeletal: Normal muscle strength, no edema.
  • Neurological: Oriented to person, place, time, and situation, normal reflexes.

Test Ordered and Diagnostic Results

1. Renal Ultrasound: Evaluates the kidneys for structural abnormalities.
2. Basic Metabolic Panel (BMP): Assesses electrolyte levels and kidney function.
3. Complete Blood Count (CBC): To rule out infection or other blood-related abnormalities.
4. Urinalysis: To check for proteinuria, hematuria, and signs of urinary obstruction.
5. Pelvic Ultrasound: If necessary, to rule out urinary obstruction.

Primary Diagnosis

Acute Kidney Failure, Unspecified (N17.9): Ken Fowler’s clinical presentation is consistent with acute kidney injury (AKI), likely due to naproxen’s nephrotoxic effects. The patient’s history of mild chronic kidney disease predisposes him to further renal impairment following NSAID use. Dehydration, hypotension, and reduced oral intake likely exacerbated his kidney function decline.

Assessment and Plan

1. Admit to Medical-Surgical Unit for monitoring and treatment.
2. Discontinue NSAIDs to prevent further kidney damage.
3. Hold HCTZ and Lisinopril, as these can worsen renal perfusion in the context of AKI.
4. Administer IV fluids for rehydration and to improve kidney perfusion.
5. Consult a Renal Specialist for further management of his AKI.
6. Monitor Input and Output by placing a Foley catheter to measure urine output.
7. Dietary Changes: Implement a low-sodium diet to manage hypertension and protect kidney function.
8. Patient Education: Counsel Ken Fowler on the risks of self-medicating with NSAIDs, especially considering his chronic conditions. Advise him to always consult with his healthcare provider before taking any new medications, including over-the-counter drugs.
9. Follow-up: Schedule a follow-up appointment two weeks post-discharge to assess renal function recovery and overall progress.

Conclusion

Ken Fowler’s iHuman case study emphasizes the importance of careful medication management in patients with pre-existing conditions such as chronic kidney disease and hypertension. The case demonstrates how NSAIDs, such as naproxen, can trigger acute kidney injury, particularly in older adults with a history of renal impairment. By working through this case study, students gain valuable experience in clinical decision-making, diagnosis formulation, and patient education, which are all crucial skills in the medical field.

This case highlights the need for careful evaluation, including comprehensive history-taking, physical examination, and appropriate diagnostic testing, to arrive at a clear diagnosis and develop an effective treatment plan. Through the iHuman simulation, students learn the importance of considering a patient’s entire medical history and how medications may interact with existing conditions.

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