What labs, imaging, and management should be ordered for a 79‑year‑old woman with a splinted distal radius fracture, nondisplaced nasal fracture, cervical strain on physiotherapy, using acetaminophen and ibuprofen for pain, and a penicillin allergy?

SOAP Note and Follow-Up Care for 79-Year-Old Female with Wrist and Nasal Fractures

SUBJECTIVE

• 79-year-old female presents for follow-up after fall yesterday
• Sustained distal radius fracture (currently splinted) and nondisplaced nasal fracture
• Currently using acetaminophen and ibuprofen for pain control
• Has scheduled follow-up with sports medicine for wrist fracture
• Receiving physiotherapy for neck pain/cervical strain
• Allergies: Penicillin (swelling), animal dander, coding

OBJECTIVE

Vital Signs: [Document BP, HR, RR, O2 sat, pain score at rest and with movement] 1

Wrist Examination:

• Inspect splint integrity and positioning
• Assess neurovascular status: capillary refill, sensation in median/ulnar/radial nerve distributions, motor function
• Evaluate for compartment syndrome signs (severe pain, pallor, pulselessness, paresthesias, paralysis)
• Document active finger range of motion - critical to assess for finger stiffness 1

Nasal Examination:

• Inspect for septal hematoma (requires urgent drainage if present)
• Assess for CSF rhinorrhea (clear fluid drainage)
• Evaluate nasal airway patency bilaterally
• Document any epistaxis or ecchymosis

Cervical Spine:

• Palpate for midline tenderness
• Assess range of motion (flexion, extension, rotation, lateral bending)
• Neurologic examination of upper extremities

Fall Risk Assessment:

• Perform Timed Up and Go test 2
• Assess gait and balance
• Review medications for polypharmacy risk 2
• Evaluate vision and postural blood pressure 2

ASSESSMENT

Primary Diagnoses:

1. Distal radius fracture, status post splinting
2. Nondisplaced nasal fracture
3. Cervical strain
4. High fall risk in elderly patient
5. Fragility fracture requiring secondary prevention workup

PLAN

Immediate Pain Management

Revise current analgesic regimen - your current plan is suboptimal for this elderly patient. 1

• Discontinue ibuprofen immediately - NSAIDs should be avoided or used with extreme caution in elderly trauma patients due to renal dysfunction risk (40% of trauma patients have moderate renal impairment), GI bleeding risk, and drug interactions 1, 3
• Continue acetaminophen 1000mg every 6 hours as first-line therapy - this is the recommended first-line treatment for elderly trauma patients 1
• Avoid opioids unless breakthrough pain is severe and uncontrolled, as they significantly increase risk of delirium, respiratory depression, over-sedation, and subsequent falls in elderly patients 1
• Consider peripheral nerve block if pain remains severe despite acetaminophen - this reduces opioid requirements and improves outcomes 1
• Apply ice packs to wrist and nose as adjunctive non-pharmacological pain control 1

Wrist Fracture Management

Immediate Instructions (Critical to Prevent Complications):

• Instruct patient to perform active finger motion exercises immediately and regularly through complete range of motion - finger stiffness is one of the most functionally disabling complications and can be very difficult to treat after fracture healing 1
• Finger motion does not adversely affect adequately stabilized distal radius fractures 1
• Keep hand elevated above heart level when possible to reduce edema 1

Follow-Up Imaging:

• No additional wrist imaging needed today if initial radiographs showed adequate alignment and splint placement is appropriate 1
• Repeat wrist radiographs at sports medicine follow-up (typically 1-2 weeks) to assess for loss of reduction 4

Rehabilitation:

• Do NOT prescribe formal physical therapy for the wrist at this time - home exercise programs are more effective than supervised physical therapy after distal radius fracture, with patients achieving 54% grip strength and 79% ROM versus only 32% and 52% with supervised therapy 5
• Provide written home exercise program instructions with training diary 5
• Early wrist motion is NOT routinely needed after stable fracture fixation - defer wrist mobilization until sports medicine follow-up 1
• Continue finger exercises as primary focus until immobilization discontinued 1

Nasal Fracture Management

• No imaging required - nondisplaced nasal fractures are clinical diagnoses 1
• No specific treatment needed for nondisplaced nasal fracture
• Apply ice packs for comfort and to reduce swelling 1
• Avoid nose blowing for 1 week
• Sleep with head elevated 30-45 degrees
• Return immediately if: clear fluid drainage (CSF leak), severe epistaxis, septal hematoma develops, or breathing difficulty worsens

Cervical Strain Management

• Continue physiotherapy as scheduled
• Maintain cervical range of motion exercises
• Avoid prolonged static positioning

Laboratory Testing (Essential for Secondary Fracture Prevention)

Order today:

• Complete metabolic panel (calcium, albumin, creatinine, electrolytes) - identifies subclinical disease increasing fracture risk 1
• Thyroid-stimulating hormone (TSH) 1
• Complete blood count with ESR 1
• 25-hydroxyvitamin D level 1
• Renal function assessment - critical before continuing any NSAIDs and guides medication dosing 3

Rationale: These tests identify frequently present subclinical diseases that increase fracture risk and guide treatment decisions 1

Osteoporosis Evaluation and Secondary Fracture Prevention

This is a fragility fracture requiring immediate intervention - secondary fracture risk is highest immediately after the fall event. 2

Immediate Actions:

• Refer to Fracture Liaison Service (FLS) today - this is the most effective organizational structure for secondary fracture prevention, achieving up to 90% treatment adherence versus much lower rates in standard care 1, 2
• Order DXA scan of lumbar spine and hip within 2-4 weeks to measure bone mineral density 1
• Order lateral thoracolumbar spine radiographs or VFA to detect subclinical vertebral fractures, which are frequent in patients with recent non-vertebral fractures and independently predict future fracture risk 1

Pharmacological Prevention (Start Today):

• Calcium 1200mg daily (dietary plus supplementation to reach total) - reduces non-vertebral fractures by 15-20% 2
• Vitamin D 800 IU daily - reduces falls by 20% and non-vertebral fractures by 15-20% 2
• Consider bisphosphonate therapy (alendronate or risedronate) after DXA results if osteoporosis confirmed - these are first-choice agents that reduce vertebral, non-vertebral, and hip fractures 1

Fall Prevention Program (Critical Priority)

Your patient has already fallen once - preventing the next fall is essential. 2

Immediate Interventions:

• Prescribe supervised exercise program: 3 sessions per week for at least 12 months including gait training, balance exercises, functional training, and resistance training 2
• Each session should include balance training, strength exercises, and flexibility work 2
• Conduct home safety evaluation - arrange occupational therapy home assessment for environmental hazard modification 2
• Medication review - assess for medications increasing fall risk (sedatives, anticholinergics, antihypertensives causing orthostasis) 2
• Vision assessment - refer to ophthalmology if not evaluated within past year 2

Follow-Up Schedule

1 Week:

• Phone call to assess pain control, finger motion compliance, and any complications
• Review laboratory results and adjust treatment accordingly

1-2 Weeks:

• Sports medicine appointment for wrist fracture reassessment with repeat radiographs
• Splint may be discontinued or continued based on fracture stability

2-4 Weeks:

• Return visit to review DXA results and spine imaging
• Initiate bisphosphonate therapy if indicated
• Assess fall prevention program enrollment and compliance

6 Weeks:

• Reassess wrist function: grip strength, ROM, Patient Related Wrist Evaluation (PRWE) score 5
• Transition to aggressive wrist mobilization exercises after immobilization discontinued 1

Patient Education

Wrist Care:

• Perform finger exercises every 2 hours while awake - move all fingers through full range of motion including making a fist, spreading fingers wide, and touching each fingertip to thumb 1
• Watch for warning signs: increasing pain, numbness/tingling, fingers turning blue/purple/pale (requires immediate emergency care) 4
• Keep splint clean and dry
• Do not remove splint except as instructed by sports medicine

Fall Prevention:

• Use assistive device (cane or walker) until balance and strength improve 2
• Remove home hazards: loose rugs, clutter, poor lighting 2
• Wear sturdy shoes with non-slip soles
• Rise slowly from sitting/lying to prevent dizziness

Medication Adherence:

• Take calcium and vitamin D daily with food for better absorption
• Continue acetaminophen regularly (not just as needed) for optimal pain control 1

Red Flags - Return Immediately If:

• Fingers become blue, purple, pale, or cold 4
• Severe increasing pain unrelieved by acetaminophen
• Numbness or inability to move fingers
• Clear fluid draining from nose (possible CSF leak)
• Severe nosebleed that won't stop
• New neurological symptoms (weakness, severe headache, confusion)
• Another fall occurs