Case Study Week Ten
Musculoskeletal and Neurologic Disorders
CC:
HPI: Will is a 69-year-old Asian male with a history of a right-hand tremor for several years. He is accompanied by his wife today to the clinic. She is very concerned because Tony has been having difficulty with balance and walking, which is becoming slower. This morning he fell while walking across the room. She saw nothing to cause him to trip. The floor is hardwood and all rugs have been removed by his wife due to concerns for falling.
He does not use a cane or walker. He was \”in a rush to get to the bathroom.\” He is not complaining of inability to move but he is cradling his right wrist in his left hand. He reports pain in his right arm that is \”like an ache but not enough that he took pain medication prior to coming to the clinic. Both tell you that he fell onto his right side, did not bump his head and was not unconscious after the fall. He was wearing his usual comfortable shoes that are his favorites.
You suspect Parkinson’s disease (PD) and wonder if he has had an examination in the past that may have found signs and symptoms of PD. Briefly describe the etiology of PD. You note from the chief complaint that he fell. What is the relationship between PD and falls? What do you consider regarding his hurry to get to the bathroom?
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The remainder of the history indicates that his family history has his parents living into their 90s until they had strokes. He takes no medications except Tylenol for occasional pain. He has not seen a provider since his retirement physical five years ago.He is active in the home, taking care not to fall, but does not use a cane of walker.
He is a retired teacher and is actively involved in a reading group as a hobby. He has been married to his wife for 50 years, she also is a retired teacher, and they have a comfortable retired lifestyle, owning a home in a neighborhood where they have many friends who also are Asian. No children. The remainder of the ROS does not contribute to or support the current problem.
PE: What would be the priority examination given his chief complaint?
What will you examine in the musculoskeletal examination?
What will you examine in the neurological examination of Will? Describe at least three neurological examinations you will perform.
Are there any other examinations that you will consider?
Diagnostics: You know that PD is primarily a clinical diagnosis, but there are several diagnostic tests that can be useful in making the diagnosis. Describe at least two diagnostic tests that may be helpful in the diagnosis of PD. Also you want to determine if there was an injury from the fall.
You understand that there was a fall with a denial of injury and pain that did not require pain medication. Are there diagnostics you would consider?
You understand that he fell on his way to the bathroom apparently with a quickened gait. Diagnostics?
Differential Diagnoses: There are at least three to consider. Describe each and your rationale for considering them. Is it possible that he has more than one diagnosis? Are they interrelated with his chief complaint?
Diagnosis: If you You diagnose Tony with early stage PD. What are some of the key principles of treatment? List at least two principles of treatment.
If you diagnose a musculoskeletal problem what would be the treatment for that?
If there are other diagnoses how would you determine to treat or not to treat?
Plan/Referrals:
If as an NP you decide not to initiate treatment for PD. what would you do instead?
Would you treat any other problem? Diagnostic reports? Rationale for treating or not treating.
Describe at least three referrals and the rationale for each.
What patient education will you offer the couple, taking into consideration social determinants of health (would you ask additional questions regarding SDH?
Follow-up: You suggest you will want to see him again in 1 month or sooner if there is a need. What are some of the things you will want to follow in addition to his musculoskeletal and neurological status? List at least three questions you will explore as you discharge him home with a referral.
Remember, the reflection is required as it is your understanding of what you learned from the case, how you were able to integrate potentially three separate diagnoses, and their relationship to the final disposition of the patient, and how you will use the knowledge you gained as well as any other comments you would like to make regarding the case.
Solution
Focused SOAP Note Template
Patient Information:
Initials: T. W. Age: 69 years Sex: Male Race: Asian
S (subjective)
CC (chief complaint): “I have been having difficulty with balance and walking, which is becoming slower. This morning I fell while walking across the room.”
HPI (history of present illness): T. W. is a 69-year-old Asian male with a history of a right-hand tremor for several years. He is accompanied by his wife today to the clinic. The patient’s wife is very concerned because T. W. has been having difficulty with balance and walking, which is becoming slower. This morning he fell while walking across the room. She saw nothing to cause him to trip. The floor is hardwood and all rugs have been removed by his wife due to concerns for falling. He does not use a cane or walker.
He was “in a rush to get to the bathroom.” He is not complaining of inability to move but he is cradling his right wrist in his left hand. T. W. reports pain in his right arm that is “like an ache but not enough that he took pain medication prior to coming to the clinic. Both indicate that he fell onto his right side, did not bump his head, and was not unconscious after the fall. He was wearing his usual comfortable shoes that are his favorites.
- Location: Right hand.
- Onset: Several years ago.
- Character: Tremor
- Associated signs and symptoms: Pain in his right arm; difficulty with balance and walking; falls.
- Timing: Re-emerging.
- Exacerbating/relieving factors: None reported.
- Severity: 7/10 pain scale
Current Medications: He takes no medications except Tylenol for occasional pain.
Allergies: No known allergies reported.
PMHx: No history of major illnesses reported.
Soc and Substance Hx: T. W. has not seen a provider since his retirement physical five years ago. He is active in the home, taking care not to fall, but does not use a cane of walker. He is a retired teacher and is actively involved in a reading group as a hobby. He has been married to his wife for 50 years, she also is a retired teacher, and they have a comfortable retired lifestyle, owning a home in a neighborhood where they have many friends who also are Asian. No children.
Fam Hx: T. W. has his parents living into their 90s until they had strokes.
Surgical Hx: No prior surgical procedures reported.
Mental Hx: No current or past mental health concerns reported.
Violence Hx: No violence or safety concerns reported.
Reproductive Hx: None reported.
ROS (review of symptoms):
GENERAL: No fever, no chills, no body weakness.
H: Does not report head injury, headache, or swelling on the head.
E: No vision issues reported.
E: Does not report hearing problems.
N: Denies nasal issues.
T: Denies gum-related problems. Reports pain while swallowing food. No evidence of drooling.
Cardiovascular/Peripheral Vascular: Denies chest pain, fast heartbeat, or tightness on the chest.
Respiratory: Denies breathing difficulties. Denies a cough.
Gastrointestinal: Reports mild constipation, denies indigestion, denies blotting, or abdominal pain.
Musculoskeletal: Has a quickened gait and reports difficulty with balance and walking, which is becoming slower. Rigidity of the right hand.
Neurological: Reports tremor on the right hand.
Genito-urinary: Denies changes in urination frequency. Does not report issues with reproductive organs.
Psychiatric: Reports mild depression.
O (objective)
Physical Exam:
Vital signs: Blood pressure: 120/80, temperature 37 degrees Celsius, RR 20, weight 70.3 kg.
General: T. W. is well groomed and neatly dressed. He is attentive and responds to questions.
Skin: Warm, hairy, no rash, no lesions.
Head: Normocephalic; no evidence of physical injury.
Eyes: Lids and conjunctivae are moist.
Ears: No blockage of ear canal.
Nose: No runny nose; no evidence of blockage.
Mouth: No lesions in the nasal mucosa, throat has no erythema.
Neck: No pain, mild stiffness. No masses or tenderness in the thyroid area.
Respiratory: Comfortable breathing. Lungs are clear. No wheezes heard.
Heart: No murmur. Normal S1 and S2. Regular heart rhythm and heart rate. No gallop. No rub.
Abdomen: No tenderness. No abdominal pain. Abdomen is flat. No masses. Normal bowel sounds.
Motor: Stiffness evidenced by trouble rising from a chair without support.
Neurological: Re-emerging tremor of the right hand. Evidence of rigidity on the right hand.
Musculoskeletal: Quickened gait; difficulty balance and walking. Slowness on hands and legs.
Diagnostic Tests:
- Perform blood tests to rule out the presence of blood disorders (Mayo Clinic, 2021).
- Perform imaging tests such as magnetic resonance imaging (MRI) and ultrasound of the brain to identify any neurological problems (Mayo Clinic, 2021).
- Perform gait analysis to assess the patient’s gait (Vilella & Reddivari, 2021).
- Conduct Screening Musculoskeletal (MS) Exam to assess joint function and determine whether an injury occurred from the previous fall (Vilella & Reddivari, 2021).
A (assessment)
- Parkinson’s disease (Primary diagnosis)
Tremor is an early symptom of Parkinson’s disease. Patients normally experience tremor even during rest. Other symptoms include slowness in walking and when performing activities, rigidity, difficulty with balance, abnormal gait, and frequent falls. Parkinson’s disease commonly affect people aged 60 years and above (Zafar & Yaddanapudi, 2020). T. W. is aged 69 years and has symptoms that match those of Parkinson’s disease making it the primary diagnosis.
- Dementia with Lewy Bodies
Although patients with Lewy body dementia usually present with tremor and rigidity, symptoms that are commonly used as diagnostic criteria for the disease are; a decline in cognitive function, memory loss, and visual hallucinations (Haider et al., 2021). Patient T. W. does not present with these other features.
- Normal pressure hydrocephalus
Symptoms of normal pressure hydrocephalus resemble those of Parkinson’s disease. However, loss of bladder control is usually used as the differentiating symptom (The Johns Hopkins University, 2021). Patient T. W. does not present with loss of bladder control, making normal pressure hydrocephalus less probable diagnosis.
P (plan)
Diagnostics
- Conduct a dopamine transporter scan (DaTscan). This is a specific single-photon emission computerized tomography (SPECT) scan that test changes in dopamine transmission (Mayo Clinic, 2021).
- Administer a Unified Parkinson’s Disease Rating Scale (UPDRS) to assess the severity and progression of Parkinson’s disease (AlMahadin et al., 2020).
- Administer the Hoehn and Yahr (HY) scale to test the level of disability caused by Parkinson’s disease and to evaluate the progression of symptoms (AlMahadin et al., 2020).
- Administer low doses of dopamine agents and monitor the patient over time for improvement in current symptoms (Lee & Yankee, 2021).
Pharmacotherapeutic Intervention:
- Administer Carbidopa-levodopa, a dopamine agents that helps to improve neurologic symptoms (Zafar & Yaddanapudi, 2020).
Non-pharmacotherapeutic Interventions:
- Register the patient in a physical fitness program (Zafar & Yaddanapudi, 2020).
- Consider music therapy to complement physical fitness program (Zafar & Yaddanapudi, 2020).
- Deep brain stimulation can help to improve symptoms of Parkinson’s disease.
Patient Education:
- Inform the patient about the risk factors of Parkinson’s disease such as familial history and environmental determinants (Lee & Yankee, 2021).
- Educate the patient to avoid environmental determinants of Parkinson’s disease such as injury on the head, increased intake of dairy products, smoking, increased coffee consumption, & alcohol use (Lee & Yankee, 2021).
- Educate the patient to adhere to the recommended treatment regimen (Lee & Yankee, 2021).
- Involve family members and discuss about meals and appropriate timing for medication treatment.
Referrals:
- Refer the patient to a physiotherapist to help him to improve balance and gait. A physiotherapist will also select age-appropriate physical activities for the patient to help him maintain an active life (Zafar & Yaddanapudi, 2020).
- Refer the patient to a mental health professional for psychological monitoring (Zafar & Yaddanapudi, 2020).
Discharge/Disposition Questions:
- Do you need support with activities of daily living?
- Are you comfortable living with family members at home?
- What are some of the issues you may want addressed as you begin self-care management at home?
Planned Follow-Up:
- Conduct follow-up after every one month to monitor patient progress.
Reflection
One major lesson that has been learned from the case study is that people aged 60 years and above are at increased risk of developing Parkinson’s disease. The clinician needs to combine information from medical history with neurological and musculoskeletal examination to make an accurate diagnosis. Treatment of patients with Parkinson’s disease should begin immediately the presence of disease is confirmed.
Combining pharmacological and non-pharmacological interventions can speed up recovery. As part of health promotion, the patient should eat a balanced diet, avoid dairy products, and engage in age-appropriate exercise. The clinician should work with family members to ensure appropriate timing of medication and positive patient outcomes. Frequent follow-up should be conducted to monitor the patient’s progress.
References
AlMahadin, G., Lotfi, A., Zysk, E. Siena, F., Carthy, M., & Breedon, P. (2020). Parkinson’s disease: current assessment methods and wearable devices for evaluation of movement disorder motor symptoms – a patient and healthcare professional perspective. BMC Neurology, 20, 419. https://doi.org/10.1186/s12883-020-01996-7
Haider, A., Spurling, B. C., Sánchez-Manso, J. C. (2021). Lewy Body Dementia. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482441/
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed., p. 359). F. A. Davis.
Lee, T. & Yankee, E. (2021). A review in Parkinson’s disease treatment. Neuroimmunology & Neuro-inflammation, 8. doi: 10.20517/2347-8659.2020.58
Mayo Clinic. (2021). Parkinson’s disease: Diagnosis. https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062
The Johns Hopkins University. (2021). Normal pressure hydrocephalus. https://www.hopkinsmedicine.org/health/conditions-and-diseases/hydrocephalus/normal-pressure-hydrocephalus
Vilella, R. C., & Reddivari, A. K. R. (2021). Musculoskeletal examination. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551505/
Zafar, S., & Yaddanapudi, S. S. (2020). Parkinson Disease. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470193/