Substitute decision maker

An elderly male has sustained multiple injuries related to a significant fall outside of his assisted living facility which required that he be taken to hospital to be assessed for injuries. The intake interview with the patient’s substitute decision maker revealed that the patient has recently been diagnosed with Type II diabetes as well as intermittent atrial fibrillation. Patient was diagnosed with frontotemporal dementia 7 years ago and has difficulty speaking.

The intake nurse records the following additional information in his chart:

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Male, 85 years old
131 lbs
167 cm

Patient was hospitalized for heart surgery in 2010 (Cardiac Bypass)


Current Medications:

metformin (500mg b.i.d) – for diabetes
ramipril (1.25mg b.i.d.) – for hypertension
hydrochlorothyazide (50mg q.d.) – diuretic for hypertension

atorvastatin (20mg q.d.) – for hypercholesterolemia
rivaroxaban (15mg q.d.) – anti-coagulant for stroke prevention due to atrial-fibrillation

The following additions are made to the chart after physical assessment:

    • Pain, bruising and swelling over posterior left elbow and left hand/wrist
    • Normal flexion and extension (with pain) of left wrist
    • Limited flexion and extension (with pain) of left elbow
    • Patient has limited and painful lateral rotation and abduction of his left shoulder with painful arc between 90 – 110 degrees in abduction
    • He is unable to fully extend his left elbow.

He shows normal ROM for extension and flexion of both wrists although his left wrist is painful on palpation and active-free movement.

He also seems to be complaining of a headache at the time of intake

 

Please answer the following questions as they relate to this scenario:

1.Which structures are the most likely to have been injured? (please be specific and support your clinical impression with specific references as to why)

2.Besides ROM, are there any additional clinical assessments you would suggest are necessary to determine the extent of this patient’s injuries?

3.Why is it important to note that this patient has a history of hypertension (high blood pressure), diabetes and dementia?

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