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Pertinent Positive and Negative Information, Missing Information

Pertinent Positive Information

An 85-year-old man with a history of falls and pain in his left shoulder following a fall is the pertinent positive information. He rates the pain in his left shoulder a 4 out of 10 and characterizes it as dull and non-radiating. Additionally, the left shoulder, arm, hip, and lower leg are bruised. In addition to his past medical history of hyperlipidemia, hypertension, coronary artery disease, dementia, chronic obstructive pulmonary disease, and benign prostatic hyperplasia, he has experienced a drop in appetite for the past several days. Atorvastatin, hydrochlorothiazide, amlodipine, amino salicylic acid, Plavix, tamsulosin, and Spiriva are among the drugs he is currently taking. He gave up drinking and smoking in 2007, is widower, and lives with his kid. A physical examination indicates a weak, reticent patient who is agreeable and well-organized. He has not had any head injuries, and auscultation reveals clear lungs. Heart murmurs absent. The abdomen lacks organomegaly and is non-tender and soft. Additionally, there is no edema but ecchymosis in the left shoulder. He has a negative empty can test, Apley scratch test and cross arms test. 

Pertinent Negative Information

Pertinent negative information includes the absence of any post-fall unconsciousness, left shoulder deformity, fever, chills, cough, shortness of breath, nausea, vomiting, diarrhea, or genitourinary symptoms. He also exhibits no abnormalities of the skin other than bruises, and no neurological deficiencies other than widespread weakness. He is not experiencing psychological distress.

Missing Information

The exact mechanism of the fall—whether it was a trip, slip, or loss of balance—is one of the missing details. The duration of the left shoulder pain is also absent, as are any previous falls or injuries. The functional state before to the fall, including the capacity to carry out daily living tasks on one’s own, and the cognitive function evaluation, including the MMSE Score, are not mentioned in the history. Additionally, there is no nutritional assessment, which would be essential in directing the patient’s care and include dietary intake/weight loss as well as a social support network and resources.

Differential Diagnoses

Left Shoulder Rotator Cuff Injury

It is likely that the patient suffered a rotator cuff injury to their left shoulder because of their history of falls and ensuing left shoulder pain. The typical presentation of rotator cuff injuries is non-radiating, dull discomfort (Doiron-Cadrin et al., 2020). Additionally, ecchymosis over the deltoid region, which suggests a muscle damage, supports the diagnosis. Cross arms, the Apley scratch test, and the negative empty can test all point to a partial-thickness tear.

Left Shoulder Dislocation or Subluxation

The force of the fall may allow for this diagnosis, which could also account for the pain and restricted range of motion. A negative cross arms test could point to a subluxation, but an MRI and X-ray would be required to confirm the diagnosis (Onks, 2021).

Osteoporotic Fracture

An osteoporotic fracture is likely, based on the client’s age and history of osteoporosis. The bruising on the hip may indicate additional fractures while the X-ray of the left shoulder, hip and lower leg are mandatory to rule out fractures (Tanski et al., 2021).

Plan Utilizing Clinical Practice Guidelines for Left Shoulder Rotator Cuff Injury

The most likely diagnosis is left shoulder rotator cuff injury, which is managed according to the plan that follows:

Pain Management

Pain is relieved by non-steroidal anti-inflammatory medications. Moreover, according to Doiron-Cadrin et al. (2020), ice packs might lessen inflammation. Other treatment includes shoulder sling, corticosteroid injections, and Tylenol. Physical therapy would also help to manage the discomfort, a basic shoulder-strengthening program.

Imaging Studies

An X-ray taken of the left shoulder would rule out a dislocation or fracture. A shoulder fracture, dislocation, or other damage may be detected or diagnosed with the help of a CT scan. The degree of the rotator cuff tear would be assessed by a left shoulder MRI (Doiron-Cadrin et al., 2020).

Orthopedic Consultation

When discussing treatment options for a verified rotator cuff tear, it is imperative to speak with an orthopedic surgeon (Doiron-Cadrin et al., 2020). For partial-thickness tears, non-surgical options include physical therapy and injections; for full-thickness tears, surgery would be the best course of action.

Fall prevention

One way to prevent falls is to evaluate potential fall risks in the client’s house. If required, the clinician might additionally suggest assistive technology like a cane or walker (Doiron-Cadrin et al., 2020). Educating patients and caregivers about fall prevention techniques is essential.

Follow-up

To guarantee continuity of care, the client requires close monitoring (Doiron-Cadrin et al., 2020). Frequent clinical visits with the primary care physician would help with close progress monitoring and need-based treatment modifications. After a 6-week evaluation, if the patient has not improved, surgical therapy should be considered. 

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