Musculoskeletal and Neurological Disorders
Felipe is a 70 year old Hispanic male who presents to the urgent care clinic accompanied by his wire and neighbor. He was transported by ambulance. 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 at all, instead, his face was drooping on the right and he was trying to speak to her but she could not understand him. 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 went to the urgent care clinic where Felipe had been for a couple of broken bones after falls. At the urgent care, a staff person came to the car and did a brief assessment. At this time Felipe could speak, slowly, to say that his right arm hurt and that he could not move it. He had no idea what had happened.
Relevant history 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. More recently, he had begun to speak of retirement, however, he had not become a citizen and so was not entitled to retirement in the US system. His need to retire was to get away from fumes that made him cough and sometimes the chemicals made him dizzy. Of course he had no health insurance as an independent painting contractor. He had “made them a good living” according to the wife, but she worries that he will not be able to work much longer, the kind of work he does, and she cannot keep him from repair in their own home. He has fallen several times, maybe he falls because he is dizzy as she does not think he has forgotten how to use a ladder. She has asked him if he has been dizzy and he has denied any dizziness. She took a job cleaning a few months ago anticipating becoming the bread winner sooner rather than later. She asks if there is any help for them financially as Felipe has never been in the hospital and his care has not cost more than he could pay over time. She said she is healthy, having had two children with her care funded by some sort of grant. However, she does not have health insurance.
Felipe had been told he had high blood pressure last year when he went to the urgent care for falling and they casted his arm. He wore the cast and the arm healed but he thought the medication for blood pressure was too expensive so he just added to his water intake and felt better. Other than all the falls and the high blood pressure she said he had had no health problems. His mother and father had something like high blood pressure, she thought. 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.
The tech at the urgent care notes that Felipe can now speak, but does not recall what happened. He can move his arm but motion is limited either by pain or injury. He is very anxious and asking the cost of the visit, wanting a cast on his injured arm and to leave. VS 165/95 H/R 68 R 18 T97.8
Felipe is speaking but his speech is slurred at times, his memory is not clear, his vision is 20/60 in both eyes and he does not wear glasses, a screening clock drawing test is normal, on the affected side, he is unable to flare his fingers, grip is weak, cannot rotate shoulder, sensation is grossly intact. The remainder of his neuro exam is normal. His ortho exam is normal with exception of his arm weakness and inability to do range of motion. The remainder of his physical exam is normal. You plan to do a more extensive exam following diagnostics that you know need to be done asap. He is given some Tylenol for pain until his diagnostics are completed.
The UC has x-ray and laboratory capability and there is a CT available to the UC as it is connected to a hospital. Initially, you order a CT of his head without contrast, a CT of his chest for the cough and the bruising injury to his left chest, a right humerus and shoulder x-ray, two views. You order a lab series of CBC with differential, full chemistry panel, as a baseline, anticipating there could be more needed. A laceration to his upper arm is wrapped for later suturing. He is taken to the hospital radiology department.
What do the social determinants of health tell you about this patient that will assist you with helping him? Consider each one and discuss the implications.
What other professionals (at least 3) would you consider bringing to this case? (You have access to them from the hospital)
What other tests do you anticipate possibly ordering? Why?
At this point you have to consider that this patient may need to be admitted, even though he is refusing for now. You understand that his wife will accept Felipe’s decisions unless it is obvious that there is a greater problem than he understands. What do you anticipate?
Differential DX (May be more than one system and may require further testing to determine) Anticipate the findings of his diagnostics and then go forward as if accurate.
What about pain? What about suturing? What about his blood pressure?
What about health insurance? What about his continuing to work? Who do you consult? What about health insurance for Lucinda?
What about future social determinants of health, especially that could offer support for this couple?
What else may be helpful?
Make some assumptions about the findings of the diagnostics, report them, and initiate a plan of care, working with Felipe and Lucinda for immediate and follow up care. Remember that you have access to the hospital for an admission, a panel of specialists for referrals, and a home-based care program sponsored by the hospital.
- Review this and previous weeks’ Learning Resources as needed.
- Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient\’s condition. Reflect on how the results would be used to make a diagnosis.
- Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
- Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
- Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with their condition(s).
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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