6565 Case Study Week Six
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.
Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products
Allergies: include medication, food, and environmental allergies separately (A description of what the allergy is, i.e., angioedema, anaphylaxis, etc. This will help determine a true reaction as opposed to intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more information is sometimes needed.
Soc & Substance Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren, if pertinent.
Surgical Hx: prior surgical procedures
Mental Hx: diagnosis and treatment. Current concerns: Anxiety and/or depression. History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: concern or issues about safety (personal, home, community, sexual . . . current & historical)
Reproductive Hx: menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: 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: Burning on urination. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
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: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format, i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)
Differential Diagnoses: List a minimum of three differential diagnoses. Your primary, or presumptive, diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Include a discussion related to health promotion and disease prevention, taking into consideration patient factors such as age and ethnic group; PMH; and other factors, such as socio-economic and cultural background.
The reflection also is included in this section. Reflect on this case and discuss what you learned. Were there any “aha” moments or connections you made?
You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Expert Answer and Explanation
Focused SOAP Note for Musculoskeletal Disorders
Felipe, 70-year-old, Male, Hispanic
CC (chief complaint): “My husband cannot speak words that have sense.”
HPI: Felipe is a 70-year-old Hispanic male brought to the hospital by his wife and neighbor. The patient was brought to the hospital by ambulance. The patient’s wife complains that her husband could not speak properly. She realized that he could not speak after he fell to the floor at home today from a ladder when cleaning windows. The wife notes that the patient might have injured his right arm because he could not even move it. His face was drooping on the right side. He might have fallen after experiencing dizziness. She also observed blood on the patient’s shirt sleeve. Associated signs include visual changes, memory loss, and difficulty moving his right arm. She took him to nearby urgent care, where the patient complained that his right arm hurt and he could not move it. He has forgotten what happened and why he feels pain in his right arm. He says that the severity of the pain on his arm is 8/10. He has not used any drug to alleviate the pain.
Current Medications: He is not under any medications at the moment.
Allergies: The has not reported food, medication, or environmental allergies.
PMH: He cannot remember when he last took his last tetanus vaccine. He has gone to urgent care for broken bones many times. He was diagnosed with high blood pressure last year. No surgeries.
Soc & Substance Hx: The patient is married with children. The patient is a private painter and has worked in this occupation for over 50 years. He likes cleaning his compound when free. The patient is from a family with low financial status. He does not have health insurance, and this has prevented him from accessing quality care. He denies using alcohol, tobacco, or illegal drugs. He only drinks when feeling pain after experiencing a fall. His work puts him at risk of developing respiratory problems. His wife says that the fumes and chemicals made him dizzy and cough.
Fam Hx: The patient has no siblings. His father and mother had a history of hypertension. His children are healthy with no major health problems. Grandchildren are also healthy.
Surgical Hx: The patient does not have a prior history of surgical procedures.
Mental Hx: The patient has no mental health problems. He does not have depression, anxiety, or experience homicidal or suicidal thoughts.
Violence Hx: He has no history of violence.
Reproductive Hx: He has no reproductive issues or sexual concerns.
- GENERAL: No weakness, weight loss, fatigue, chills, or fever.
- HEENT: No vision problems. No double vision. No sneezing, hearing loss, runny nose, or congestion.
- SKIN: No rash or itching.
- CARDIOVASCULAR: No edema, chest pain, chest pressure, palpitations, or chest discomfort.
- RESPIRATORY: No cough, shortness of breath, or sputum.
- GASTROINTESTINAL: No blood or pain in the abdomen. No diarrhea, vomiting, nausea, or anorexia.
- GENITOURINARY: No burning when urinating. No urgency to urinate.
- NEUROLOGICAL: The patient’s wife reports that the patient sometimes experiences dizziness when painting. No headache, ataxia, or paralysis.
- MUSCULOSKELETAL: He reports that he feels pain in this right arm. He also reports that he cannot move the arm due to pain.
- HEMATOLOGIC: The patient’s wife reports seeing blood in his shirt sleeve.
- LYMPHATICS: No history of enlarged nodes or splenectomy.
- PSYCHIATRIC: No history of anxiety, bipolar disorder, or depression.
- ENDOCRINOLOGIC: No heat or cold problems.
- REPRODUCTIVE: He is sexually active.
- ALLERGIES: No history of rhinitis, asthma, hives, or eczema.
- Vital Signs: BP 165/95, RR 18, HR 68, T 97.8, Wt. 72kgs, Ht, 5’7″
- General: The patient looks anxious about the cost of the visit. He wants to go home as soon as possible. He cannot walk. Appears ill. His memory has been affected. He is alert and oriented to place, people, time, and events. He does not know what happened to him. His speech is slow. He answers questions correctly.
- HEENT: Normal hair distribution on the head. No external trauma on the head. Face drooped. No scalpel swelling. Vision is 20/60 in both eyes. he does not wear glasses. Normal screening clock drawing test.
- Cardiovascular: Normal heart rate and rhythm. Chest clear.
- Respiratory: Chest expansion symmetrical. Normal breathing rate. Breathing sounds are equal and clear bilaterally. No bruising, poor effort, or cough
- Musculoskeletal: No abnormal movement on the hands. No deformities on the hand joints. No pain when MPC joints are compressed. Normal shape, size, and symmetry of the forearms, upper arms, and elbows. No involuntary movements on the arms. No muscle atrophy. Positive for pain, swelling, tenderness of the elbows of the right arm to palpation. Cannot rotate the shoulder. He cannot flare his fingers. Weak grip. Grossly intact sensation. Left-arm weak. The right arm is warm to the touch.
- Neurological: Positive for memory loss. Normal attention and concentration.
- CT of the Head and chest: No injury to the head and chest.
- Shoulder X-ray: Shows bone breakage in the right shoulder.
- CBC: Report will be available in 24 hours.
- Full chemistry panel: All the organs function properly.
- EGK: Normal
- Sprain: The primary diagnosis for this case is a sprain on the right arm. Kemler et al. (2016) note that the symptoms of a sprain include swelling, pain, and difficulty moving the injured area. The patient in the case experiences pain in the right arm and cannot move it. When examining the right arm, the patient was so protective of it and did not want me to tough it. The physical examination also shows that the patient’s right should is swollen, and he cannot move it. The arm is also weak and warm to the touch. Jarzyński et al. (2020) note that muscle sprains can prevent a patient from using the injured muscle. The patient cannot use his right hand. All the symptoms qualify this as the primary diagnosis.
- Concussion: Concussion has been included as part of the diagnosis because the patient has a memory problem. He says that he does not remember what happened to him. He also has a vision of 20/60. A concussion is a traumatic brain injury caused by a blow or bumps to the head (Ho et al., 2020). The symptoms of concussion include vomiting, headache or pounding pressure in the head, feeling foggy or hazy, sensitivity to noise or light, dizziness, blurry vision, nausea, and feeling down. The disease can also cause memory loss and confusion (McCarty et al., 2019). The patient does not experience most of the symptoms, making the disease a secondary disorder.
- Bell’s palsy: Bell’s palsy causes weaknesses in one’s facial muscles (Somasundara & Sullivan, 2017). The weakness can lead to drooping of the face. The symptoms of the disease include drooling, facial droop, mild to total paralysis of one side of the face, pain on the affected side, headache, changes in amount to saliva and tears produced, and increased sensitivity to sound. The disease has been included in the diagnosis because the patient’s face drooped. However, it is a secondary diagnosis because the patient does not experience most of its symptoms.
Treatment: The primary diagnosis for this case is a sprain. Hence, the patient will be provided with a compression bandage to reduce swelling of the injured area. A compression bandage will also make the patient feel much better (Borra et al., 2020). The patient will also be prescribed acetaminophen tablets 3000mg orally thrice a day. In other words, he will take two pills every six hours to help him manage the pain.
Health promotion and Education: The patient should be educated to gently start using the injured area after the first two days to improve blood circulation. However, the patient should avoid exerting pressure on the area. They should also follow the treatment plan.
Referrals: The patient will be referred to a physical therapist to help with stretching therapy.
Discharge: He will be discharged in a stable condition.
Follow-Up: The patient should come to the clinic after a week for a check-up. However, if the condition worsens, he can call the hospital line for assistance.
The case was about a patient who had a muscle problem in his arm as a fall. I have learned in this case that comprehensive assessment can help identify the exact problem impacting the patient. I have also learned that nurses should always rely on evidence-based guidelines and literature in making treatment decisions and diagnoses. I supported the diagnosis with both literature and laboratory tests. Overall, the case was exciting and educative.
Borra, V., Berry, D. C., Zideman, D., Singletary, E., & De Buck, E. (2020). Compression wrapping for acute closed extremity joint injuries: A systematic review. Journal of Athletic Training, 55(8), 789–800. https://doi.org/10.4085/1062-6050-0093.20
Ho, R. A., Hall, G. B., Noseworthy, M. D., & DeMatteo, C. (2020). Post-concussive depression: evaluating depressive symptoms following concussion in adolescents and its effects on executive function. Brain Injury, 34(4), 520-527. https://doi.org/10.1080/02699052.2020.1725841
Jarzyński, T. O. B. I. A. S. Z., Pękala, P. A. T. R. Y. K., & Baranowska, A. (2020). Analysis of neurological symptoms and mechanisms in dislocation, sprains and strains of joints and ligaments at neck level. Polski Merkuriusz Lekarski: Organ Polskiego Towarzystwa Lekarskiego, 48(288), 410-414. http://pml.medpress.com.pl/ePUBLI/free/PML288-410.pdf
Kemler, E., Thijs, K. M., Badenbroek, I., van de Port, I. G., Hoes, A. W., & Backx, F. J. (2016). Long-term prognosis of acute lateral ankle ligamentous sprains: High incidence of recurrences and residual symptoms. Family Practice, 33(6), 596-600. https://doi.org/10.1093/fampra/cmw076
McCarty, C. A., Zatzick, D., Hoopes, T., Payne, K., Parrish, R., & Rivara, F. P. (2019). Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial. Trials, 20(1), 1-14. https://doi.org/10.1186/s13063-019-3662-3
Somasundara, D., & Sullivan, F. (2017). Management of Bell’s palsy. Australian Prescriber, 40(3), 94–97. https://doi.org/10.18773/austprescr.2017.030
Write a fully developed and detailed APA essay addressing each of the following points/questions. There is no required word count; be sure to completely answer all the questions for each question in detail.