Musculoskeletal and Neurological Disorders
You are an NP in an urgent care, hospital-based, with access to the diagnostics in the hospital and some of the specialists.
Your first patient of the day is brought in via the wheelchair kept in the lobby with a man in the chair, slumped, held in by another man and a woman pushing the chair. The MA goes to assist them and brings them straight to your room, without stopping at admissions telling you this is not a clinic or hospital patient at this organization.
Felipe is a 70-year-old Hispanic male who presents to the primary care urgent care clinic accompanied by his wife and neighbor. The history is provided by Lucinda, his wife. According to the history, he had been on a ladder cleaning windows and then had fallen to the floor, in the same room as Lucinda. He fell from a short ladder onto his arm. He had fallen before, several times, so she was not too concerned. He could not move his right arm without pain. She called the neighbor and friend who helped her get him 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 has no health insurance as an independent painting contractor. She said he is healthy but had been told he had “a little high blood pressure” when he had it checked at the local pharmacy screening. He knew he could not afford the medication so he did nothing except to tell her he could no longer eat salt on his food. He takes no medications. Sometimes he gets “a little confused with his words and is sometimes “restless in the evening, maybe almost forgetting where he is. but it goes away in minutes.” He has had “all his shots” at the health department. He also went to the health department for Covid testing twice and the tests were negative. He has been careful to wear a mask when on painting jobs but she admits his mask is not a heavy one. He works when he has a job, which is almost all the time because he takes on anything he is capable of doing just to have work close by and where he usually knows the people. His parents died in their 80s of old age. He has no siblings. The couple has two children who live away and do not visit. They are healthy. Mostly the couple relies on friends in the neighborhood for any needs. They have no car, mostly relying on the bus for transportation. Felipe gets jobs walking distance from their home in a mostly Mexican American neighborhood where they feel safe. They walk to the grocery store a few blocks away and pull a wheeled cart with the groceries to get them home. She said they walk several miles each week for errands and just for exercise. She “cooks healthy as she can, but their diet is primarily Mexican, his favorite foods”. His weight is unchanged “forever”. He has no problems climbing ladders or other physical requirements for his work except for the occasional falls, which he always has had, nothing new. He does not use tobacco, never has, and they do not drink alcohol. But when he falls, he takes Tylenol or maybe “a shot of whiskey for the pain”. He does not drink otherwise. He did not want to come to the clinic today, but she insisted this was a little worse than earlier falls because his arm is bleeding, and it is bent, and he did not seem awake until the time he saw the hospital. Of course there is not past history except for the information provided by Lucinda.
VS 165/90 H/R 76 R 18 O2 Sat 96% T 98 Wt. 160 pounds Ht. 70 inches
Felipe is awake with slow speech, complaining of pain in his right arm. He tells you he does not remember what happened except he did not hit his head, only his arm and he does not want to be in the hospital. There is blood on his face, his right shirt sleeve and he cannot move his right arm. When someone else attempts to move it he cries out.
Felipe has come to a clinic that shares, x-ray and lab diagnostics with the adjoining hospital.
What is your approach? Record a SOAP note with appropriate history, physical exam, provisional diagnoses, differential diagnoses, as you work your way through the assessment, diagnostics, treatment, and plan. Some of the history is very subtle so read it closely. Do not add information—work with what you have and if you would need other information, note that but that it is unavailable.
Differential DX must consider ortho and neuro.
Mentally construct his social determinants of health as you listen to Lucinda’s history and speak with Felipe. Other than the lack of insurance (he is an immigrant, never a citizen, not eligible for Medicare.) what are strengths and problems that you recognize.
You have access to other health professionals due to the co-location to the hospital. The hospital is a safety net hospital. What does that mean for this patient? (If you do not know, look it up.)
What referrals might you make, list all that are appropriate and the reasons for consulting? What is the disposition of this patient? Follow up?
Reflect on your learning from this case.
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.