Ken Fowler ihuman Case Study

Ken Fowler ihuman Case Study

HPI Statement: Ken Fowler is a 70-year-old hypertensive male on Lisinopril, HCTZ, and metoprolol referred to the ED by his primary care provider (PCP) for evaluation of elevated creatinine levels (3.2mg/dL). He also reports a three day history of nausea and vomiting currently with dry heaves. The vomitus is non-bilious, non-bloody, and non-projectile with clear or residual food particles. It worsens with meals and is relieved with decreased/no oral intake. The nausea and vomiting is associated with poor oral intake, easy fatigability, decreased urine volume, and orthostatic hypotension. One week ago, he informs of experiencing lower back pain due to straining while lifting a heavy box in his basement. He self-medicated with naproxen, an NSAID. Since then, the pain has gradually resolved. He declines experiencing weight loss, abdominal pain, and changes in the color of urine.

Current medications: HCTZ, lisinopril, and metroprolol

Allergies: None

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)

Social hx: He consumes a glass of wine with dinner either once or twice every week.

ROS

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.

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.

Objective data- Ken Fowler ihuman case study 

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

Assessment

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

PLAN

Diagnoses

• Primary Diagnosis with ICD-10 code, rationale, and evidence based resources
  • Acute Kidney Injury (AKI) (Pre-renal Azotemia) secondary to intravascular volume depletion ICD10-N17.9: also referred to as acute renal failure (ARF), AKI indicates a sudden but reversible decrease in kidney function as evidenced by the glomerular filtration rate (GFR). Its most important identifying characteristic is a decrease in urinary output. Although there are many forms of AKI, the pre-renal form occurs as a result of decreased blood flow to the kidneys either as a result of hypotension, hypovolemia, or other causes (Hoste et al., 2018). Fowler’s clinical presentation of a sudden increase in plasma creatinine levels within one week of NSAID therapy (naproxen) while on his antihypertensives; an ACE  inhibitor (Lisinopril) and diuretic (HCTZ) , a history of decreased oral intake, decreased urinary output and a three-day history of vomiting increase suggest pre-renal AKI. Currently existing evidence from literature reveals the following risk factors of pre-renal AKI; heart failure, dehydration, hemorrhage, anaphylaxis, and sepsis. Patients will report symptoms of  anorexia and nausea with the use of diuretics, oliguria (decreased urinary output), hypotension, signs of dehydration, and signs of worsening intravascular volume depletion(ascites and  piting edema) (Hoste et al., 2018). While Fowler’s history is consistent with pre-renal AKI, the physical exam findings of dry mucous membranes, orthostatic hypotension, and tachycardia also support this diagnosis.

Differential Diagnoses

• • Differential diagnoses with rationale and evidence based resources. 3-5 differential diagnoses are required.(5pts)
    • Urinary Obstruction ICD10- N13. 9: this is a disorder of the urinary tract which occurs   as a result of obstructed flow of urine. It has several causes such as; hyperplasia, benign prostatic hypertrophy, urethral strictures, urolithiasis and neuropathic bladder dysfunction (Nicola & Menias, 2018). Although the obstruction can present with a wide range of symptoms, more often, it involves flank/abdominal pain, dysuria, nocturia, decreased force of urinary stream, urinary urgency, fever, hematuria, night sweats, and unintentional weight loss, GI symptoms of vomiting, nausea, diarrhea, or constipation. The physical exam may be significant for a distended bladder and an enlarged prostrate. However, the lack of evidence of obstruction on renal ultrasound decreases the likelihood of this diagnosis.
    • Medication-related side effect ICD10-T88.7: Ken Fowler has a history of NSAID use (naproxen) for back pain. This drug acts by inhibiting inhibit both cyclooxygenase (COX) isoenzymes COX-1 and COX-2 hence decreasing the synthesis of prostaglandins (Bensman, 2020). However, this subsequently causes reversible renal ischemia, decreased glomerular hydrostatic pressure, and ultimately AKI.
    • Intrarenal AKI: the intrarenal causes of AKI include acute tubular necrosis, a prolonged pre-renal AKI state, post infectious glomerulonephritis, malignant hypertension, atheroemboli, among other causes (Hoste et al., 2018). The lack of history, physical examination, and diagnostic findings to support infectious processes, or a procedure to release an emboli rules out this diagnosis.
• Medications
  • Admit the patient
  • Discontinue  Naproxen or any other NSAID taken by the patient
  • Hold the patient’s anti-hypertensives (Lisinopril and HCTZ)
  • Insert a Foleys urinary catheter to monitor  urine output
  • Start Ken Fowler on Fluid therapy. Initiate IV saline for fluid replacement until normalcy return in kidney function
• Additional ancillary tests needed, referrals, and follow up:
  • Complete Blood Count
  • Renal Ultrasound
  • Urinalysis
  • Basic Metabolic Panel (BMP)
  • Eosinophils, urine
  • Sodium (Na⁺), urine
  • Pelvic ultrasound
• Referrals to specialists, therapists (physical, occupational), counselors, or other professionals
  • Referral to  a dietician for  nutrition counselling with regards to maintaining a DASH diet
  • Referral to  a nephrologist  for further evaluation of renal function
• Follow-up instructions
  • Return for follow-up in 7 days, 3 months,  and subsequently every 6 months for evaluation of progress
  • Following therapy with a thiazide diuretic, return for annual evaluation of creatinine and potassium levels (Unger et al., 2020).  
• Social Determinants of Health (SDH), Health Promotion and Pt risk factors: 5 pts
  • Discuss and consider appropriate age screening based on the  recommendations by the USPTF
    • Screening for colorectal cancer
    • Annual dental exam
    • Screening for diabetes mellitus(DM) type 2
    • One-time screening for abdominal aortic aneurysm
    • Annual eye-exam
    • Annual flu shot
    • Referral to behavioral counselling to promote health
    • Screening for  hepatitis C virus
    • Screening for lung cancer

• Discuss adherence and compliance to the prescribed antihypertensives following discharge.
• Discuss lifestyle modification to enhance treatment outcomes
  • restricting salt intake (2300mg) and salt containing foods (fast foods and processed foods)
  • Maintain a healthy diet (DASH diet) rich in fruits, vegetables, whole grains, and polyunsaturated fat. Decrease intake of foods rich in saturated fats, sugar and trans fats (Unger et al., 2020).
  • Take healthy drinks; moderate the consumption of coffee, black and green tea and replace with helpful beverages (tea, cocoa, and beetroot juice)
  • Moderate the intake of alcohol. Alcohol increases the risk of cardiovascular disease and worsens hypertension. Only take up to 2 drinks. Avoid binge drinking (Unger et al., 2020).
  • Consider weight management. Monitor your diet, regularly engage in resistant and aerobic physical activity. This includes moderate intensity aerobic exercises such as cycling, jogging and swimming (for approximately 30 minutes 5-7 days weekly) (Unger et al., 2020).
  • Smoking is a risk factor for heart disease, lung cancer, and chronic obstructive pulmonary disease (COPD). It results in a poor prognosis in people diagnosed with hypertension.
  • NSAIDs increase the risk of renal failure particularly in hypertensive patients. Educate the patient to avoid the use of NSAIDs or any other OTC medications without the input of a licensed provider.
  • Discuss with the patient about home BP self-monitoring, maintaining up-to-date records and bringing to the clinic during every appointment.

References

Bensman, A. (2020). Non-steroidal anti-inflammatory drugs (NSAIDs) systemic use: the risk of renal failure. Frontiers in pediatrics, 7, 517.

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.

Nicola, R., & Menias, C. O. (2018). Urinary obstruction, stone disease, and infection. Diseases of the Abdomen and Pelvis 2018-2021, 223-228.

Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., & Schutte, A. E. (2020). 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension, 75(6), 1334-1357.

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