15 Jun Question Musculoskeletal System and Patient
Question
Musculoskeletal System and Patient Encounters (graded)
Class, in this thread we will be looking at musculoskeletal system terminology and related patient encounters. The purpose of this thread is to familiarize you with the Key Concepts found in TerminalCourse Objective (TCO) 3. You must address all of the questions located after the example of dischargesummary and patient encounter of Carol Champion.
Discharge Summary
Admission Diagnosis: Multiple compression fractures of T12, L1, L2, and L4
Discharge Diagnosis: Same as above, non-acute fractures
History of Present Illness: This is a 70-year-old African-American female with a long history of multiple fractures dating back to 1992. She has a history of significant osteoporosis diagnosed in 1998. The patient also has a history of osteoarthritis and had a right total hip replacement in 2000. Two days prior to admission, the patient missed the final step coming down the stairs in her home. She caught hold of the railing but twisted as she did so and developed some back pain. This became progressively worse over the next 2 days to the point where she was having difficulty ambulating and she went to the Emergency Room.
On evaluation in the ER, it was noted that she had compression fractures of the T12, L1, L2, L3, and L4 vertebrae. However, these could not be ruled out as new or old fractures due to lack of previous X-rays in this area. The patient was admitted for further evaluation.
Past Medical History: The patient is retired and lives in an independent living apartment in the Pine Valley retirement community. She does not smoke and has no alcohol intake. She has osteoporosis and osteoarthritis. Also of note is that approximately 10 days prior to admission, the patient had sustained a distal radius fracture of her left forearm for which she was treated with a splint by an orthopedist.
Physical Examination: This is a well-developed, well-nourished elderly female in no acute distress. She had moderate discomfort on movement. Her HEENT exam was essentially normal. Her lungs were clear. Heart had a regular rate and rhythm. Abdomen was soft and nontender. Her rectal area showed good tone. Her back showed moderate tenderness to palpation in the upper lumbar and lower thoracic area. Neurologically, she was completely normal with cranial nerves being intact. Motor was 5/5 in all extremities except for the left extremity, which was not examined secondary to the arm being in a splint. She had deep tendon reflexes 2+ and equal. Her sensory exam was normal.
Hospital Course: The patient was admitted and on the day following admission, she had a bone scan that revealed moderate degenerative joint disease of the T&L (thoracic and lumbar) spine with no evidence of acute compression fractures. The patient was placed on bed rest and was started with physical therapy and ambulation with which she has steadily progressed with decreasing pain and tenderness. The patient is now ambulating using a walker with a platform for her wrist splint.
Social Services and Physical Therapy were consulted. She is ambulating well with her walker and it is felt she will do well staying with members of her family over the next 10 to 14 days, after which time she will be able to go back to living in her apartment.
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