Primary care practice for follow-up after an urgent care

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Reference no: EM133914156

A mother brings her 5-year-old son to your primary care practice for a follow-up after an urgent care visit 2 days ago. His mother took him to urgent care after he complained of left elbow pain and had stopped using the arm. The mother states the elbow pain began after a fall earlier that day. She said he had been running around the house; he fell forward and hit his left elbow. When asked about the injury, the patient said, "I hurt my elbow. Mom got mad because I was running so much." The mother states she thinks he hurt his back too when he fell, but otherwise there were no other injuries. He had an x-ray at the urgent care. The mother states there were no fractures, but the physician in the urgent care recommended a follow-up because the boy has a dislocated elbow. Mother did not bring the radiology report for the PCP to review. He has been doing well with icing his arm, taking ibuprofen 150 mg TID, and resting his arm.

Review of Systems:

Positive for left elbow pain, low back pain, and bruising on the lower back. There is no head injury, joint swelling, numbness, weakness, or paresthesia of upper or lower extremities. All other symptoms are negative.

Physical Exam, Focused:

Psychiatric: Engaged during the exam and between questions and exam with a downward gaze; appears anxious and withdrawn.

Skin: Four linear bruises each 15 cm × 2 cm on buttocks in various stages of healing. No other bruises or lesions.

Musculoskeletal: Mild tenderness of lateral left forearm; no focal tenderness of elbow. Refuses active range of motion, full passive range of motion left elbow. Full active and passive range of motion right elbow and bilateral fingers, wrists, and shoulders.

Questions:

1. What other questions would you ask regarding the patient and parents' history?

2. What would be other focus areas of the physical assessment?

3. What laboratory and/or diagnostic tests would you order?

4. Should tests/imaging studies be ordered? Which ones? Why?

5. What are your three priority differential diagnosis? Give rationale.

Reference no: EM133914156

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