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6565 Case Study Musculoskeletal and Neurological Disorders Felipe is a 78 year old Hispanic male who presents to the primary care clinic accompanied by his wife and neighbor. The history is provided by Lucinda, his wife. According to the history, he had been on a ladder cleaning windows and then had fallen to the floor, in the same room as Lucinda. He fell from a short ladder onto his arm. He had fallen before, several times, so she was not too concerned. He could not move his right arm without pain. She called the neighbor and friend who helped her get him to the clinic. Relevant history from wife Lucinda, is that Felipe has worked as a painter for over sixty years, having been brought to the US from Mexico as a child by his parents. His father got work as a painter and as soon as the boy was old enough and able enough, he began to help with the painting work. He had no health insurance as an independent painting contractor. She said he is healthy but had been told he had “a little high blood pressure” when he had it checked at the local pharmacy screening. He knew he could not afford the medication so he did nothing except to tell her he could no longer eat salt on his food. He takes no medications. Sometimes he gets “a little confused with his words and is sometimes “restless in the evening, maybe almost forgetting where he is. but it goes away in minutes.” He has had “all his shots” at the health department. He also went to the health department for covid testing twice and the tests were negative. He has been careful to wear a mask when on painting jobs. He works when he has a job, which is almost all the time. His parents died of old age. He has no siblings. The couple has two children who live away and do not visit. They are healthy. Mostly the couple relies on friends in the neighborhood for any needs. They have no car, mostly relying on the bus for transportation. Felipe gets jobs walking distance from their home in a mostly Mexican American neighborhood where they feel safe. They walk to the grocery store a few blocks away and pull a wheeled cart with the groceries to get them home. She said they walk several miles each week for errands and just for exercise. She “cooks healthy and their diet is primarily Mexican, his favorite foods”. His weight is unchanged “forever”. He has no problems climbing ladders or other physical requirements for his work. He does not use tobacco, never has, and they do not drink alcohol. But when he falls, he takes “a shot of whiskey for the pain”. VS 155/90 H/R 76 R 18 T 98 Felipe is alert and complaining of pain in his right arm. He tells you he did not hit his head, only his right arm. He wants it fixed so that he can leave as he does not have money to pay for care. Felipe has come to a clinic that shares xray and lab diagnostics with an adjoining hospital. What is your approach? Record a SOAP note as you work your way through the assessment, treatment, and plan. Some of the history is very subtle so read it closely. Do not add information—work with what you have and if you would need other information, note that but that it is unavailable. Differential DX must consider ortho and neuro. Mentally construct his social determinants of health as you listen to Lucinda’s history and speak with Felipe. Other than the lack of insurance (as an immigrant, never a citizen, not eligible for Medicare) what are strengths and problems that you recognize. How will you use this information? You have access to other health professionals due to the co-location to the hospital. The hospital is a safety net hospital. What does that mean for this patient? (If you do not know, look it up.) What referrals might you make, list all that are appropriate and the reasons for consulting? Reflect on your learning from this case. SOAP format

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