Nu627U3peerresponseNatasha

Pertinent positives:

Fall 2 days ago while home alone; dull, non-radiating pain to left shoulder; rates pain 4 out of 10; reports increased unsteadiness for one month; hit corner of bed with rolling walker causing fall landing on left side; been sore all over and moving less since fall; bruising o shoulder, arm, hip and lower leg; decreased appetite over last couple of days; memory issues at times; generalized weakness and soreness; pain increases with movement

Pertinent negatives:

Denies hitting head; denies loss of consciousness; denies altered ROM; denies joint deformity; denies fever; denies chills; denies cough; denies shortness of breath; denies nausea, vomiting, diarrhea; denies GU symptoms; has taken no medications for pain; denies sleep abnormalities; denies dizziness; denies lightheadedness; denies weakness in one particular area.

Missing information

History of previous falls? Recent medication changes? Average daily oral fluid intake? Average daily meal intake? Recent weight changes? Any groin pain since fall? Any OTC or herbal medications? Date of last vision exam? Usual daily routine for ADLs and meals? Is patient alone during the day every day? Is patientâ€™s living area easily maneuverable with assistive devices? Is the patientâ€™s bed or furniture placement an obstacle for accessing the bathroom?

Differential diagnoses

Difficulty in walking resulting in accidental fall

Orthostatic hypotension episode

Weakness secondary to malnutrition or dehydration

Plan will include each item below:

Diagnostics:

Based on the information provided it seems that the nature of the fall was accidental while ambulating with the rolling walker, but given the patientâ€™s age and generally frail presentation, it would be essential to perform a through head-to-toe assessment with a review of medications and directed attention to any previous incidences of falls. While the patient is in the office, I would also perform an orthostatic challenge as his blood pressure is a bit on the lower side. I would also order CBC, CMP, 25(OH)VitD level, and prealbumin. (Boltz et al., 2020) If the patient has not had a recent visual exam, I would refer to Ophthalmology for an examination. I will also consider an x-ray of the left shoulder if the patient has persistent pain. The rationale for not ordering this immediately is that the patient has no alteration in ROM and has no observable joint deformity. If the patient reported groin pain during the questions, I would also consider a hip x-ray as this may be a presentation of a severe hip injury. (Warshaw et al., 2022)

Although it would not be relevant to the acute assessment and treatment to this encounter, I would also order a DEXA scan for this patient. Even though osteoporosis is more frequently considered a post-menopausal female problem, geriatric males can also be affected and possess a higher mortality risk after suffering a fall. (Bello et al., 2023) Fractures in males over the age of 70 are most commonly related to the presence of osteoporosis and this patient presents with multiple identified risk factors such as being a white male over the age of 70, COPD, history of alcohol use, history of smoking, and having a low BMI. (Bello et al., 2023)

Therapeutics

I would advise the patient on using non-opioid analgesics like acetaminophen and as well as nonpharmacological pain modalities such as ice for pain while encouraging gentle ROM exercises during the recovery.

I would also consider the discontinuation of hydrochlorothiazide with instructions for patient to have home blood pressures monitored at home daily. The patientâ€™s BP is on the lower side, 104/62, when considering that blood pressure parameters in the ambulatory community dwelling elderly population is SBP<130. (Epocrates, 2024) This will also decrease urinary frequency, in addition, patient does not have documented CHF to be at risk for fluid overload with this medication change.

Educational:

Effective patient education tactics in this case should include the patientâ€™s family as well since he lives in the home with them. They should be educated on the importance of the overall goal of maintaining safe physical functioning as well as fall risk and prevention strategies including adequate lighting, elimination of fall or trip hazards, proper footwear when ambulating and having a clear path for ambulation. (Warshaw et al., 2022) Education should also be provided on the preference of nonopioid and nonpharmacological pain interventions as opioids dramatically increase fall risk in the elderly. Education also should be provided on the importance of adequate nutrition and hydration including accessible small frequent meals throughout the day when he is alone.

Consultation/Referrals

OT referral for assessment of home environment and safe use of assistive device.

PT referral for evaluation for exercise/balance program.

Nutritional/dietician referral, provide information for local meals for seniorsâ€™ programs if patient is alone throughout the day.

Consider fall alert device if patient is alone for extended periods of time.

Orthopedist referral if exam/studies reveal fracture.

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