CASE 7 - Right Arm Pain

Question 1

Doctor, do you think I will be able to move my arm again like before?

Answer 1

I hope so, but first we need to find out exactly what is causing your problem.

Question 2

Specific questions to ask:

Answer 2

1. Description of fall.
2. LoC.
3. Seen by doctor since? Any Tx?
4. Reasons for NOT seeking medical attention?
5. Living conditions.
6. Bad Tx in his son’s house? Do you feel safe at home?

Question 3

PEx:

Answer 3

1. HEENT ==> Check for bruises, neck movements.
2. CV ==> A.
3. Pulmonary ==> A.
4. Exam of the arms ==> Compared both arms in terms of strength, ROM (shoulder, elbow, wrist), joint stability, sensation, DTRs, pulses.

Question 4

Closure:

Answer 4

1. Discuss initial diagnostic impressions.
2. Discuss initial management plans ==> F/U tests — alternative living options such as assisted living — social work assistance.
3. Offer statement of support — “Your safety is my primary concern, and I am here for help and support when you need it.”
4. Ask if the SP had any other questions or concern.

Question 5

Sample closure:

Answer 5

1. Mr. Green, you may have a fractured bone, a simple sprain, or a dislocation of the shoulder joint.
2. We will need to obtain an x-ray of your shoulder and arm to make a diagnosis, and more precisely imaging studies such as an MRI may be necessary as well.
3. Your safety is my primary concern, and I am here to offer you help and support whenever you need it.
4. Sometimes living with a family can be stressful for the whole household.
5. Have you considered moving to an assisted-living community or to an apartment complex for seniors? If you are interested, I can arrange a meeting with our social worker, who can assess your social situation and help you find the resources you need.

DYHAQFM

Question 6

DDx 1 — Humeral fracture:

Answer 6

1. Pain following recent fall on outstretched arm.
2. Pain increases with arm movement.
3. Tenderness over upper and middle right arm.
4. Restricted ROM.

Question 7

DDx 2 — Shoulder dislocation:

Answer 7

1. Pain following recent fall on outstretched arm.
2. Pain increases with arm movement.
3. Right arm externally rotated and slightly abducted.
4. Pain and ROM on shoulder exam.

Question 8

DDx 3 — Osteoporosis:

Answer 8

1. Advanced age.

Question 9

Workup:

Answer 9

1. XR-right shoulder and arm.
2. MRI shoulder.
3. Bone density scan (dexa).

Question 10

Additional DDx:

Answer 10

1. Elder abuse.

2. Rotator cuff tear.