Posted: June 14th, 2023

Musculoskeletal and Neurological Disorders

Assessing, Diagnosing, and Treating Patients With Complex Conditions
Number of sources: 3
Paper instructions:
Use the Focused SOAP Note Template to address the following:

Subjective: What details are provided regarding the patient’s personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: Describe your “aha!” moments from analyzing this case.

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Musculoskeletal and Neurological Disorders

Felipe is a 70 year old Hispanic male who presents to the urgent care clinic accompanied by his wife and neighbor. According to the history, he had been on a ladder cleaning windows and then had fallen to the floor, called out and his wife, Lucinda, heard him and went to help him up. He had fallen before, several times, so she was not concerned at first. When she reached him to help him up, she noticed that he could not tell her what happened, he could not speak words that made sense to her. Since he could not move his right arm and there was blood on his shirt sleeve, and he seemed to be in pain she called the neighbor who helped drag him into the car and they came to the clinic.

Relevant history from wife Lucinda, is that Felipe has worked as a painter for over fifty years, having been brought to the US from Mexico as a child by his parents. His father got work as a painter and as soon as the boy was old enough and able enough he began to help with the painting work. He had no health insurance as an independent painting contractor. She said he is healthy, but has been told he has high blood pressure. He could not afford the medication for it so he takes no medications. They have two children who live away and do not visit. They are healthy. Parents died of old age.

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He has no siblings. Their children are healthy. Felipe does not use tobacco or drink, except when he falls and has pain he takes some whiskey for the pain. They eat a Mexican diet, always have. Felipe’s weight has been the same since she has known him. The neighbors are friendly and they are their friends. Both children live miles away and do not visit but neither has health problems that she knows about.

VS 165/95 H/R 76 R 18 T 98

Felipe is more alert and complaining of pain in his right arm and asks why it is bleeding through his shirt. He cannot recall his name and tells you he is dizzy.

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Felipe has come to a clinic that shares xray and lab diagnostics with an adjoining hospital.

What is your approach? Record a SOAP note as you work your way through the assessment, treatment, and plan.

Consider other professionals (at least 3) that you would consider bringing to this case? (You have access to them from the hospital)

Differential DX must consider ortho and neuro.

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What about pain? What about suturing? What about his blood pressure?

Subjective

Patient is a 70-year-old Hispanic male who presents to the urgent care clinic with a chief complaint of fall from a ladder.
He states that he was cleaning windows when he lost his balance and fell to the ground. He hit his head on the floor and landed on his right arm. He immediately felt pain in his arm and was unable to move it. He also felt dizzy and confused.
His wife found him on the ground and called 911. He was taken to the hospital by ambulance.
He has no significant past medical history. He does not smoke or drink alcohol. He takes no medications.
He is married and has two adult children. He is a retired painter.

Objective

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Vital signs: BP 165/95, HR 76, RR 18, T 98.6
General: The patient is a well-developed, well-nourished male in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. There is no evidence of head trauma.
Neck: No jugular venous distension. No carotid bruits.
Chest: Lungs are clear to auscultation.
Heart: Regular rate and rhythm. No murmurs, rubs, or gallops.
Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly.
Extremities: Right arm is swollen, ecchymotic, and tender to palpation. There is no evidence of fracture.
Neurological: The patient is alert and oriented to person, place, and time. He is able to follow simple commands. There is no focal neurological deficit.

Assessment

The patient is a 70-year-old male with a fall from a ladder. He presents with a right arm contusion and possible neurovascular compromise.
Differential diagnosis:
Right arm contusion
Right arm fracture
Right arm nerve injury
Concussion
Subdural hematoma

Plan

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The patient will be admitted to the hospital for further evaluation and treatment.
Diagnostic tests:
X-ray of the right arm
CT scan of the head
Neurological exam
Treatment:
Pain medication
Immobilization of the right arm
Follow-up with orthopedic surgeon

Reflection notes

This case is a reminder of the importance of evaluating patients for potential neurological injuries after a fall.
The patient's age, fall height, and neurological symptoms all raise the possibility of a serious neurological injury.
It is important to perform a thorough neurological exam and order appropriate diagnostic tests to rule out a serious injury.
Early diagnosis and treatment of neurological injuries is essential to improve patient outcomes.

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Orthopedic surgeon
Neurosurgeon
Physical therapist

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