Case Study No.

_1____ Name:____Sarah Doren_________

Guest Speaker: ____Andrew T_________ Date:___11/15/21______________

Patient Presentation:
Discuss your preconceived ideas about the patient based only on the diagnosis and patient’s
demographics.

When I was told the patient’s age (85 y/o) and demographics (African American Male) I had
preconceived ideas about a patient that was not super mobile or healthy which ultimately turned
out to be very wrong when we found out he performs home exercises (on his kitchen table) and
was highly independent with mobility prior to injury.

Interview:
What were your top 3 questions? Which question was your best question? Compare and
contrast your questions to the guest speaker’s questions.

1. Please tell me about your fall. (best question)

2. What did your doctor say about your fall?
3. How have the symptoms in your shoulder and hip changed since they started?

Missed:
Hip pain 10/10 with weightbearing
Shoulder pain 8/10 with AROM
How are you feeling today?
Lightheaded because he hadn’t eaten yet this AM (no history of DM)
What was PLOF?
Independent with all house and yard work.
Wife, sister and grandchild had all passed away within 8 months
Denies unexplained weight loss

At the time, I thought that asking the patient what the doctor said about the fall was our best
question but after realizing that the fall was likely syncopal in nature I think our best question
was really asking in general about the fall (assuming the patient responded descriptively to that
question to the point of us asking what caused the fall = syncope). The guest speaker did ask
for intensity of the pain which was a very important piece of information that we missed but
hopefully would have picked up on when we saw the current state of the patient and considered
prior level of function.

Physical Exam:
Compare and contrast your list of tests and measures to the guest speaker’s list in regards to
efficiency, the patient’s comfort, and pertinent information obtained from the tests.

Our Exam:
1. Vitals (HR/BP/RR/SpO2)
 2. Palpation and observation of area of symptoms
3. Gait observation
4. AROM shoulder (flexion/abduction/IR/ER)
5. Gross strength of shoulder (flexion/abduction/IR/ER)
6. AROM hip (flexion/ext/IR/ER)
7. Gross strength of hip (flexion/ext/abduction/IR/ER)
8. STS
9. Balance (berg components)
10. LE Dermatomes
11. Hip Joint play (distraction and compression)

His Exam
1. Gait > antalgic on R with SPC
2. STS with minA
3. Vitals (BP 95/47)
a. HR = 150 / BP = 95/47
4. Cannot raise shoulder > 60 degrees of flexion
5. Pitting edema BLE, not warm, no pain
6. No signs of dislocation of R GH joint
7. Stood for 3 minutes with maxA without AD

REFER TO ED > NSTEMI

Tran’s exam was different than ours in that he did not perform any additional tests or measures
after realizing the vitals. We did decide to stick with seated shoulder assessment once we
realized that the patient was hypotensive but we did not gather enough of the vitals to fully halt
the examination like Tran did.

Treat, Refer, Both:

What was your decision? Discuss the thought process that led you to this conclusion. Be sure to
include any information that either confirmed your suspicions or was misleading.

I decided to treat and refer. My plan was to treat the patient for his musculoskeletal shoulder
pain and refer back to the physician for the 10/10 hip pain with concern for a missed fracture or
AVN. I did not have an NSTEMI on my radar. Unfortunately, I did not keep the setting in mind
and was not as alarmed as I should have been when informed of the patient’s blood pressure.
When the patient reported that he had not eaten yet that day, I actually thought that the patient
was likely dehydrated, since hypotension is common among the elderly when dehydrated. I
realize now that knowing the HR was vital (vitals are vital) for catching this medical emergency.
Hopefully in real life I would have made sure to check the vitals again at a later point of the
appointment and have had another chance to catch this. I do see how an outpatient therapist
could very easily miss something like this.