NRNP 6550 Week 7, Exam Conditions of the Renal and Genitourinary Systems

Name: Ken Fowler Age: 70 years Sex: M Ht: 5'10" (178.0 cm) Wgt: 190 lb (86.0 kg) (BMI 27.3) NOTES FROM i-HUMAN ASSESSMENT: 1) Observations: warm and sweaty 2) Chief complaint: Nausea and fatigue QUESTIONS: (ask the patient up to 100 questions) 1) How can I help you today? "I went to see my doctor this morning because I have been feeling bad for the past few days. I'm tired, with nausea & vomiting. Well, he examined me and ordered some labs, and then told me that "kidneys are failing," something about a big change in my creatinine and that I needed to come to the emergency department. He told me to bring the test results here with me. [Test results today: creatinine 3.2 mg/dL; 1 month ago Test results 1.1 mg/dL; urine protein = 400 mg microalbuminuria] Do you understand what all that means? I sure don't!" 2) Do you have any other symptoms or concerns we should discuss? I also feel exhausted, probably from all the vomiting and not eating. 3) When did your nausea start? It started three days ago, I woke up feeling nauseous and started throwing up everything I ate. 4) What are the events surrounding this start of your nausea and vomiting? Nothing really happened that I can think of. 5) Do you have difficulty breathing? Uh… no. 6) When do you fatigue start? Just the last few days. 7) Do you have a problem with fatigue/tiredness? Yup 8) Does your fatigue come and go? No. 9) Have you gained or lost weight or intentionally, despite normal appetite and exercise? Uh… no. 10) Have you gained weight? No. 11) Has there been a change in your urination frequency? Actually, I have been peening less recently. 12) What is the color of urine, has it changed recently? It's usually fine, but I have been peeing less recently 13) Does anything make your fatigue/tiredness better or worse? No. 14) Do you have pain anywhere? If so where? I hurt my back last week, but that's fine now. 15) Have you noticed swelling in any part of your body? No 16) Can you tell me about any current or past medical problems she had? I have high blood pressure. I take medications for that. I was told last month my blood pressure has caused some kidney damage. Something about my protein in my urine. Oh, about a week ago I pulled my back lifting a heavy carton when I was cleaning out my garage. It was pretty painful so I took something for the pain. My back is really pretty good right now, but then this nausea vomiting began. 17) Any previous medical, surgical, or dental procedures? Yes. I had my tonsils out as a kid and then my appendix out about 35 years ago now. 18) What treatments have you had for the pain in your back? Just Naproxen. 19) Are you taking any prescription medications? I take lisinopril, metoprolol, and hydrochlorothiazide for BP. I have not taken anything for the last 24 hours because I feel so sick, can’t keep the pills down. 20) Do you have any pain in your back? Not anymore 21) When you urinate, have you noticed any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, or any changes in frequency? Uh, no. In fact, I am barely peeing at all. 22) When are the events surrounding the start of your difficulty urinating? That’s not a problem for me. 23) When you pee, is a stream or flow of urine weak or do you dribble? No 24) Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety or bloating? Yes, I have already told you about my nausea and vomiting. But none of the other stuff. My poop is normal 25) How severe is your nausea and/or vomiting? I have not eaten much of anything in the last three days, so I am not sure how to answer that question. Vomiting is and miserable business so for me it is bad. 26) Does anything make your nausea and/or vomiting better or worse? It does get worse when I eat, that's why I haven't eaten much. 27) What treatments have you had for nausea and/or vomiting? Nothing 28) Do you have any problems with fatigue, difficulty sleeping, or intentional weight loss or gain, fevers, or night sweats? Yeah I feel exhausted, but I think it is because of my nausea… just keeps me up at night. No fevers 29) Does your fatigue/tiredness improve after a good night's rest? No 30) What does your vomit look like? Clear or residual food particles, but I haven't eaten for over 24 hours 31) When do you nausea and/or vomiting start? It started 3 days ago, I woke up feeling nauseous and started throwing up everything I ate. 32) Do you have diabetes? Uh… no. 33) What are the events surrounding the start of your back pain? I picked up a box the wrong way. 34) When was the last physical? Don't remember 35) Do you have kidney problems? Not up to now. My doctor sent me here because he was worried about that. HINT: 1 of 5 You have asked 10 key questions. 23 key questions remain. You need: • 4 more in Patient Orientation • 4 more in Chief Complaint Sx/Sx Characteristics • 3 more in Associated Symptoms • 2 more in PMH • 1 more in SH • 9 more in ROS Your current Hx efficiency is 9%. 36) What is your name? Ken Fowler 37) Where are you? In the Emergency Room 38) What time is it? Around 4:50 pm 39) How old are you? Didn’t you read my chart? 40) Do you leak urine (urine incontinence)? No. 41) When and what were the results of your last prostate exam? Not that long ago. It was normal. 42) Does anything make you fatigue tiredness better or worse? No. 43) How often are you nauseous or vomiting? It’s just been the last few days. 44) What are the events surrounding your fatigue/tiredness? It started about the same time as all the vomiting. 45) Do you have any other symptoms associated with your fatigue/tiredness? Just a nasty I'm vomiting. I feel so weak with it 46) Do you become more weak or tired with exertion? I am so tired without even doing anything. 47) Do you have any muscle pain or cramping? My back hurt last week, but it's better now. 48) How much water/Floyd do you drink a day? It is hard to keep anything down, I have not been able to drink even water. 49) Do you drink alcohol? If so, what do you drink and how many drinks per day? I drink a glass of wine with dinner frequently once or twice per week, but I have not done that for over a week now. 50) Do you now or have you ever smoked or chewed tobacco? I've never smoked 51) do you use any recreational drugs? If So what? Uh… no 52) Do you drink caffeine beverages or eat chocolate? Usually two cups of coffee in the morning. 53) Do you have any allergies? No 54) Are you taking any over the counter or herbal medication? I am not taking anything now, but when I strained my back I started taking naproxen. I guess that was about 7 to 10 days ago. It took a couple of pills twice a day. It really helped my pain. Do you think they screwed my stomach and that is why I have so much nausea? 55) When that you last take your medication? This morning. 56) Do you have any problems with itchy scalp, skin changes, moles, thinning of the hair, or brittle nails? Uh… no 57) Do you have any problems with headaches that don't go away with aspirin or Tylenol, double blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throat, or difficulty swallowing? Nope 58) Do you experience chest pain discomfort or pressure, pain/pressure/dizziness with exertion or getting angry, palpitations, decrease exercise tolerance, or blue/cold fingers and toes? Not at all. But I am not worried about my heart or anything should I be? 59) Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or speeding production? No 60) Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, nick or shoulder pain, or hip pain? Nope 61) Have you noticed any bruising, bleeding gums, nosebleeds, or other sites of increase bleeding? No. 62) Do you have problems with heat or cold intolerance, increased thirst, increase sweating, frequent urination, or change in appetite? I feel a bit thirsty, but the nausea keeps me from drinking because I am afraid all I will do is vomit it up back up. I just hate vomiting. 63) Do you have any problems with, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? No this is, but I am a bit lightheaded when I stand up and when I feel weak and exhausted. Not tingling or numbness or actually passing out. 64) Do you have problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or seen things that you know are not there? Before getting sick, no. 65) Have you been feeling sad, depressed or hopeless, if so how often do you feel this way? Uh, no. 66) Have you been more irritable or angry lately? No. 67) How would you describe your moods? Pretty good. I don't think that's my problem. HINT: 2 of 5 You have asked 25 key questions. 8 key questions remain. You need: • 1 more in Patient Orientation • 4 more in Chief Complaint Sx/Sx Characteristics • 3 more in Associated Symptoms Your current Hx efficiency is 28%. 68) Can you describe how you fell? Uh… why are you asking me this? 69) Can you describe what you were doing when you felt like headed? Nothing. I just stood up is all. 70) Do you have any other symptoms or concerns we should discuss? I also feel exhausted, proud from older vomiting and not eating. 71) Do you have any pain in your flanks? Uh… no 72) Do you ever feel/have a problem with Lightheadedness? 73) When did your lightheadedness is start? Just the last day or so. 74) Have you had problems with low blood pressure before? I don't have that problem 75) How severe is your blood pressure? Not bad period when I check it my blood pressure is usually 124 to 134 76) Do you have any history of high lipids or triglycerides? Uh… no 77) When do you have blood pressure start? About 10 years ago 78) What do you think might be causing your symptoms? It's all jumbled to me. The lab results and all that. I hope you can figure out and make me feel better. 79) What did the pain in your back feel like? My back does not hurt anymore 80) Have you recently lifted something heavy or used your back initial waist or posture? Yes the box in my basement and that's what caused the pain in my back. But that's gotten better now. 81) How do you injure yourself? I didn't hurt myself HINT: 2 of 5 You have asked 25 key questions. 8 key questions remain. You need: • 1 more in Patient Orientation • 4 more in Chief Complaint Sx/Sx Characteristics • 3 more in Associated Symptoms Your current Hx efficiency is 23%. 82) Do you feel unwell, not normal or just “not yourself” (malaise) lately? Not generally, but I sure don't feel well right now. 83) How is your overall health? Pretty good, up till now. 84) Are there any diseases that run in your family? My father had died when he was 65. He had high cholesterol and bad heart. My mother had rheumatoid arthritis but died from his stroke. My sister is in treatment for breast cancer. 85) When did you last urinate? Do you really need to know that? 86) Do you urinate frequently during the night? No more than most guys my age I suppose. 87) Have you passed any stones in your urine? No 88) Is your urine pink or red in color (blood in the urine)? No. 89) When you urinate, do you feel that you could not completely empty your bladder? Nope 90) Does anything make your lightheadedness better or worse? Standing up is what causes it. I haven't kept anything down for the last three days. Maybe if I felt better I will get better. 91) Are you eating just before going to bed? No 92) Describe activities shortly before bedtime. Nothing usual to tell you. HINT: 2 of 5 You have asked 25 key questions. 8 key questions remain. You need: • 1 more in Patient Orientation • 4 more in Chief Complaint Sx/Sx Characteristics • 3 more in Associated Symptoms Your current Hx efficiency is 21%. 93) Are you having trouble concentrating or making decisions well? If so how often? No, I don't have that problem 94) Have you had the pain in your abdomen before? Why you asking me that? I don't have pain there 95) Do you have any problem remembering things? No 96) Does your nausea and or vomiting come and go? No. 97) How quickly does your nausea and/or vomiting come on? Pretty quickly. I mean when I had to throw up I run for the bathroom. 98) Do you are waking frequently from sleep? Not usually 99) Do you feel more fatigued tired in the morning? No. 100) How quickly does your fatigue/tiredness come on? Within a day. Questions asked after Clinical feedback: 1) What happened? Not sure why you want to know? I think told you about my PCP telling me to come in because of the lab results? 2) Have you had nausea and or vomiting like this before? No never. I just don't feel very well. 3) Have you been vomiting anything that looks like blood or coffee grounds? No. That will be horrible. 4) Do you have any pain or other symptoms associated with your nausea or vomiting? I pulled my back last week lifting a box out of my basement. The pain is finally getting better period but that doesn't have anything to do with my vomiting. Oh, I have been getting lightheaded if I stand up too quickly. 5) Do you have frothy urine? Not that I have noticed. 6) Do you have any pain in your abdomen? I don't really have any belly pain, but my stomach muscles seem a bit sore, probably from all the vomiting I have been doing. 7) Have you lost weight? I don't really know. CLINICAL FEEDBACK: Hx Performance: You missed asking eight of the 33 key questions. Missed questions: Patient Orientation ̵What happened? Chief complaint Sx/ Sx characteristics: ̵Have you had nausea and or vomiting like this before? ̵Has there been any change in your nausea or vomiting overtime? ̵Have you been vomiting anything that looks like blood or coffee grounds? ̵Do you have any pain or other symptoms associated with your nausea or vomiting? Associated symptoms characteristics: ̵Do you have frothy urine? ̵Do you have any pain in your abdomen? ̵Have you lost weight? Risk factors: PMH: ̵N/A Environmental: ̵N/A Etiology: ̵N/A HPI/ROS: ̵N/A ------------------------------------------------------------------------------------------------------------------- Height/weight 5' 10" (178.0 cm) - 190 lb (86.0 kg) (BMI 27.3) Temp: 99.9F BP: Left arm, 108/60 Ortho BP (standing) 94/46 RR: 20 HR: 100 (normal) A/Ox4 SpO2: 98%$ SpCO2: 1% eTCO2: 38 mmHg --------------------------------------------------------------------------------------------------------------------- PHYSICAL EXAM: Assessment: Skin, hair, nails: • Inspect skin overall: general skin warm, drying; no pallor, jaundice, rash, scaling, or ulceration; no clubbing or cyanosis; sparse peripheral hair. • Inspect hair color, distribution, thickness: thickness and distribution pattern typical for patient’s gender and age. • Inspect nails: Nails without ridging, pitting, or peeling. • Test capillary refills – fingers: blanche time of 3-4 seconds; suggestive of dehydration. • Test capillary refills – toes: normal capillary refill • Quincke’s test: blanching observed