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 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.
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
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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.
Felipe has come to a clinic that shares X-rays 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.
- What about pain?
- What about suturing?
- What about his blood pressure?
- Focused SOAP Note Template
Solution
Focused SOAP Note
Patient Information:
Patient Initials: Mr. F., Age: 70, Sex: Male, Race- Mexican
S.
CC (chief complaint): Pain and bleeding in the right arm.
HPI:
Location: Arm
Onset: Hours ago
Character: Dull
Associated signs and symptoms: Bleeding
Timing: Throughout
Exacerbating/relieving factors: N/A
Severity: 8/10 pain scale
Current Medications: N/A
Allergies: No known food or drug allergies
PMHx: Mr. F is not up to date with the vaccination schedule. He rarely visits the hospital due to limitations in health insurance.
Soc & Substance Hx: Mr. F has worked as an independent painting contractor for 50 years. He was brought to the US from Mexico as a child by his parents. He has no health insurance having worked as an independent contractor painter. He has two children who live away and do not visit. He denies using tobacco but acknowledges to taking whiskey to ease pain when he falls.
Fam Hx: The patient has poorly managed hypertension. His children are healthy with no known illnesses. He has no siblings. His parents died of old age.
Surgical Hx: No prior surgical procedures
Mental Hx: No history of anxiety and/or depression. No history of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Has no concern or issues about safety. He lives in a safe neighborhood and is supported by neighbors and friends.
Reproductive Hx: Not sexually active
ROS:
GENERAL: Pain and bleeding on his right arm. No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies burning on urination.
NEUROLOGICAL: No headache. Is experiencing dizziness and memory loss. No syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Has pain on the right arm
HEMATOLOGIC: Right arm injured and is bleeding
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: No penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: BP 165/95, HR 76, R 18, T 98
General: Pain in the right arm
Hematologic: Bleeding
Neurological: Dizziness
Diagnostic results:
Computed tomography (CT) scan – A CT scan usually takes pictures of the brain and would be effective in showing bleeding or damage to the brain cells.
Magnetic resonance imaging – MRI uses a strong magnet and radio waves to make pictures. The diagnostic test can rule out other health issues like tumors which have similar symptoms to stroke.
Electrocardiogram (ECG) – This test usually detects and records the heart’s activity. It allows the doctor to know if atrial fibrillation is caused by a stroke.
A.
Differential Diagnoses:
Stroke (I63.9)
The first differential diagnosis for the patient is hemorrhagic stroke. A hemorrhagic stroke happens when an artery in the brain ruptures and leaks blood (An et al., 2017). The leaked blood puts pressure on the brain cells damaging them. Hemorrhagic stroke can be caused by high blood pressure and aneurysms. The patient has a history of uncontrolled high blood pressure.
Parkinson’s disease (G20)
The second differential diagnosis if Parkinson’s disease which is a progressive nervous system disorder. The condition begins with a tremor on one hand with other symptoms including slow movement, stiffness, and loss of balance. Individuals may also experience difficulty speaking and dizziness.
Osteoporosis (M81.0)
The third differential diagnosis is osteoporosis. Individuals with the condition have a higher risk of falls due to weakness of the muscle and spine kyphosis (Misiorowski, 2017). Low bone density is one of the main reasons that individuals with the condition get fractures.
Hemorrhagic strokes can be managed using endovascular procedures. The doctors usually insert a long tube which then installs a device like a coil to manage bleeding. Surgical treatment could also be used especially if the bleeding is caused by a ruptured aneurysm, a doctor might use a metal clip to stop blood loss.
Parkinson’s disease can be managed by Dopamine promoter, cognition-enhancing medication as well as Anti-tremor (Jankovic, 2020). Physical exercise might also help to build muscle and enable one to gain body strength.
Osteoporosis can be managed using Risedronate, strontium ranelate, and denosumab which have been associated with an increased bone mass density. Treatment is likely to lower the risk of falls and associated complications like fractures.
The patient’s age and economic status are two important factors that would affect the design of the treatment plan. He lacks health insurance which limits his access to necessary care for the management of hypertension. The patient is seventy years old which exposes him to deterioration of health and vulnerability to falls.
Four professionals that I would consider bringing into this case include a physical therapist due to the patient’s history of multiple falls, a social worker who would assist in helping the patient access hypertension medication, a neurologist to assist in diagnosis and management of stroke and a radiologist to establish or rule out fractures from the fall.
Reflection
The patient agrees that at his age he should not engage in high-risk activities like painting especially in high places due to his pre-existing hypertension and history of falls. He also agrees to engage in low-intensity physical activity as well as adhere to hypertension medications to prevent complications and the burden of disease.
References
An, S. J., Kim, T. J., & Yoon, B. W. (2017). Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. Journal of stroke, 19(1), 3–10. https://doi.org/10.5853/jos.2016.00864
Jankovic, J., & Tan, E. K. (2020). Parkinson’s disease: etiopathogenesis and treatment. Journal of Neurology, Neurosurgery & Psychiatry, 91(8), 795-808.
Misiorowski W. (2017). Osteoporosis in men. Przeglad menopauzalny = Menopause review, 16(2), 70–73. https://doi.org/10.5114/pm.2017.68596