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I. Client background and history (occupational profile)
a. Age, gender, occupati
I. Client background and history (occupational profile)
a. Age, gender, occupation, support system, interests, life roles, and more.
II. Diagnosis
a. Clinical presentation (here you will perform your literature review and tell me what it is expected from a patient with the same or similar diagnosis (from the literature)
b. Symptoms (what you can see in YOUR patient/client regarding diagnosis – not from the literature, but real life)
c. Comparison of symptoms with typical clinical presentations (support with evidence) (here you will compare/contrast what is expected (found in the literature) with YOUR particular patient/client.
d. Prognosis
e. Medications
Summary
References
Margaret Smith is a 78-year-old retired elementary school teacher who lives alone in a one-bedroom apartment in a retirement community after her husband passed away three years ago. She has two daughters and four grandchildren who visit her often and provide assistance with housekeeping, grocery shopping, and meal preparation. Mrs. Smith enjoys reading books, gardening, and crocheting. She also likes to take walks in the park or by the beach with her family. Despite suffering from degenerative joint disease or osteoarthritis affecting her shoulder and hands, Mrs. Smith is relatively healthy for her age. Unfortunately, on April 12, 2024, Mrs. Smith fell while going to her backyard to attend to her garden. She sustained a proximal humerus fracture on her right shoulder and was hospitalized. After her hospital stay, she was transferred to a skilled nursing facility to receive physical and occupational therapy to help her recover and regain her independence.
Clinical Presentation:
A proximal humerus fracture is a common injury that occurs when the upper part of the humerus bone near the shoulder joint breaks. This type of fracture usually results from a traumatic event such as a fall onto an outstretched arm, a direct blow to the shoulder, or high-energy impact during activities like sports or motor vehicle accidents. The clinical presentation of a proximal humerus fracture is characterized by significant pain and swelling in the shoulder region. The affected individual may experience tenderness when touched over the fracture site, and there may be visible deformity or bruising around the shoulder area. Movement of the arm is often limited and accompanied by pain, particularly when attempting to lift or rotate the arm. In some cases, the fracture may cause nerve or blood vessel damage, leading to symptoms such as numbness or tingling in the arm or hand, or even loss of circulation.
NOTE!!!!
This is what I have so far. Just add information and add citations and reference from a peer reviewed articles. 5 years or more recent.
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