Case 7 - 74 yo M with R arm pain Flashcards
1
Q
Information gathering
A
CC Onset Precipitating events Description of the fall LOC Location Weakness/paralysis Numbness/loss of sensation Progression of pain Pain anywhere else Seen by a doctor since then Any treatments Alleviating and exacerbating factors Reason for not seeking medical attention Living conditions Social history Bad treatment in his son's house Do you feel safe at home? Current medications Allergies Nature of reaction to aspirin PMHx PSHx Social Hx (occupation, alcohol, tobacco and exercise)
2
Q
Physical examination
A
Head and neck exam (check for bruises and neck movements)
CV exam
Pulmonary exam
Exam of arms (strength, range of motion, joint stability, sensation, DTRs, pulses)
3
Q
Closure
A
Alternative living options, such as assisted living
Social work assistance
Do you have any questions for me?
4
Q
Differential diagnosis
A
Humeral fracture
Shoulder dislocation
Osteoporosis
5
Q
Diagnostic work-up
A
XR - R shoulder and arm
MRI - shoulder
DEXA
