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An 85-year-old male presents with a status post right mid-humerus fracture that occurred three months previously secondary to a fall. The patient reports that the arm was placed in a sling for six weeks with instructions from the physician to avoid moving it. The patient’s past medical history includes emphysema and a history of shortness of breath, an enlarged prostate, and previous fractures resulting from multiple falls spanning over the last two years. The patient’s past surgical history includes a right total hip replacement performed approximately one year ago. The patient’s current medications include prednisone. The patient rates his right arm pain at between 5/10 and 7/10.

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Following the history and systems review what are some of your concerns with this patient?

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The major concerns with this patient are safety issues, particularly fall prevention. The patient has also been prescribed prednisone, which can increase the propensity for fracture.

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Make a list of those health issues with this patient that will impact how you plan the intervention.

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The health issues that would impact the intervention plan include the history of emphysema and of shortness of breath. In addition, the patient has had a total hip replacement of the right hip, which could be affecting his balance.

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In addition to examining the patient’s shoulder, what other aspects of the patient’s condition should you evaluate?

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Why do you think the patient has been prescribed prednisone?

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Prednisone, at high doses, is used to treat various cancers. Given the patient's enlarged prostate, he may have been diagnosed with prostate cancer necessitating the need for further questioning.

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The physical examination revealed the following positive findings:

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  • Vital signs are within normal limits.
  • Observation reveals mild thoracic kyphosis, and varus at both knees.
  • Active range of motion of right shoulder: forward flexion (65 degrees), abduction (60 degrees), external rotation (20°), internal rotation (40°), extension (20°). Right elbow flexion within normal limits, but elbow extension (-25°). All other active range of motions of the upper extremity are within normal limits.
  • Strength testing was deferred as, given the patient's history with multiple fractures, only light resistance could be used.
  • The balance and gait assessment revealed that the patient staggered and almost lost his balance when asked to get up from the treatment table. These gait pattern shows and increased base of support, a slight right lower extremity limp, and a decreased stride length with a left hip hike.

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Given the positive findings from the physical examination, what will be included in your initial plan of treatment?

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What are your short-term goals for this patient?

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