Charles Peterson Ihuman Case Study

Charles Peterson is a 72-year-old male presenting with a fall and suspected closed head injury, complicated by his history of Parkinson’s disease and recent changes in activities of daily living.

In this comprehensive guide, we’ll walk you through how to approach his case, from initial history-taking through physical examination to the final assessment of fall risk and neurological status. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this complex neurological case simulation involving an elderly patient with multiple risk factors.

Charles Peterson Ihuman Case Overview (Doorway Information)

Patient Overview: Charles Peterson is a 72-year-old Caucasian male presenting with a chief complaint of “fall with head injury” that occurred while walking at home. He describes losing his balance and hitting his head on the floor, denying any loss of consciousness. The patient has a significant history of Parkinson’s disease, which has been affecting his mobility and balance over recent months.

Key Background Information:

• Age/Gender: 72-year-old male
• Chief Complaint: Fall with suspected closed head injury
• Mechanism of Injury: Lost balance while walking, hit head on floor
• Loss of Consciousness: Denies LOC
• Associated Symptoms: Balance difficulties, declining ADL performance
• Significant History: Parkinson’s disease, reports losing balance while walking
• Current Medications: Carbidopa/Levodopa and a multivitamin
• Living Situation: Lives with wife on family farm, retired farmer
• Functional Status: Wife reports changes in Charles’ ability to complete activities of daily living

The patient appears alert and oriented x 4 but demonstrates some forgetfulness at times. He has visible bruising in the left parietal region and reports mild head pain (3/10). His presentation is classic for fall-related head injury in elderly patients with movement disorders, making this an excellent case for learning systematic neurological assessment and fall risk evaluation skills.

Charles Peterson (72 y/o male) – Fall and Head Injury Assessment

• CC: Fall with suspected closed head injury
• MSAP: 72-year-old male with Parkinson’s disease who fell at home, hit head on floor, denies LOC, visible head trauma
• Associated symptoms: Balance difficulties, declining functional status, mild head pain
• History: Parkinson’s disease, retired farmer, lives with wife, wife reports ADL changes
• High fall risk

History Questions:

• How can I help you today?
• Can you tell me exactly what happened when you fell?
• Did you lose consciousness at any time?
• Do you remember everything about the fall?
• Any other symptoms we should discuss?
• Do you have any allergies?
• Are you taking any OTC or herbal medications?
• Any new or recent changes in medications?
• How would you describe your pain right now (scale 1-10)?
• Where exactly does your head hurt?
• Does anything make the pain better or worse?
• Have you had any nausea or vomiting since the fall?
• Any vision changes or blurred vision?
• Have you felt dizzy or lightheaded?
• Any weakness or numbness anywhere?
• How has your balance been lately?
• Tell me about your Parkinson’s disease and current symptoms
• How long have you been taking your current medications?
• Have you had any recent medication changes?
• Has your walking or balance changed recently?
• Tell me about your typical daily activities
• Have you fallen before? When was the last time?
• Do you use any walking aids or assistive devices?
• How has your sleep been?
• Any tremors or stiffness that’s gotten worse?
• Tell me about your home environment
• Do you have any safety equipment at home?

Physical Exam:

• Vitals: Temperature, pulse, BP, respirations, SpO2, pain scale
• General appearance: Level of consciousness, alertness, orientation
• Neurological assessment:
  • Glasgow Coma Scale (GCS)
  • Mental status examination
  • Cranial nerve assessment
  • Motor function and strength
  • Sensation testing
  • Deep tendon reflexes
  • Coordination and cerebellar function
• Head and neck examination:
  • Visual inspection for trauma, bruising, swelling
  • Palpation of skull and cervical spine
  • Assessment for signs of basilar skull fracture
• Cardiovascular assessment:
  • Heart rate and rhythm
  • Blood pressure (sitting and standing if appropriate)
• Parkinson’s-specific assessment:
  • Tremor evaluation
  • Rigidity assessment
  • Bradykinesia assessment
  • Postural stability
• Fall risk assessment:
  • Gait evaluation
  • Balance testing
  • Environmental hazard assessment

Assessment Note:

C.P. is a 72 y/o Caucasian male presenting with fall-related head injury occurring at home while walking. Patient has significant history of Parkinson’s disease with recent functional decline per wife’s report. Physical exam reveals visible bruising to left parietal region, mild head pain (3/10), alert and oriented x 4 but with some forgetfulness. No loss of consciousness reported. Vital signs stable. Patient demonstrates typical Parkinsonian features including mild tremor and bradykinesia. High fall risk per protocol due to age, Parkinson’s disease, and history of balance difficulties.

Diagnostic Tests: Head CT to rule out intracranial injury, neurological monitoring Diagnosis: Closed head injury with concussion, fall risk related to Parkinson’s disease Plan:

• Neurological monitoring q4h x 24 hours
• Fall precautions and safety measures
• Continue current Parkinson’s medications as prescribed
• Physical therapy evaluation for fall prevention
• Occupational therapy assessment for ADL modifications
• Patient and family education on fall prevention strategies
• Follow-up with neurology and primary care provider

Charles Peterson SOAP Note

Patient: Charles Peterson

Subjective Data

CC: 72-year-old male presents with “fall and hit my head”

HPI: 72-year-old male presents today with complaints of falling at home earlier today while walking. The patient describes losing his balance and hitting his head on the floor, specifically impacting the left side of his head. The patient denies any loss of consciousness and states he remembers the entire event. Reports mild head pain rated 3/10, described as constant with a steady pattern that does not radiate. Pain started immediately when he fell. Patient denies nausea, vomiting, vision changes, or dizziness. Has a significant history of Parkinson’s disease and reports increasing difficulty with balance and walking over recent months. Wife confirms patient has had changes in ability to complete daily activities independently.

Medications: Carbidopa/Levodopa (Sinemet), multivitamin

Allergies: No known allergies (NKDA)

PMH: Parkinson’s disease, reports no other chronic medical conditions

PSH: Denies any surgical procedures

Hospitalizations: None reported

Health Maintenance: Regular follow-up with neurologist for Parkinson’s disease management

Family History: Non-contributory for this presentation

Substances: Denies tobacco, alcohol, or illicit drug use

Home Environment: Lives with wife on family farm, retired farmer. Wife reports concern about safety at home due to balance issues.

Employment: Retired farmer

Diet: Regular diet, no specific restrictions

Sleep: Reports adequate sleep, some difficulty due to Parkinson’s symptoms

Exercise: Limited due to balance and mobility issues

Safety: High fall risk due to Parkinson’s disease and balance difficulties

Objective Data

ROS: (Appropriate ROS based on neurological presentation)

General: Alert and oriented x 4 but demonstrates some forgetfulness. No acute distress. Cooperative with examination. Reports feeling “okay” except for mild head pain.

Skin, Hair and Nails: Visible bruising/ecchymosis in left parietal region. No other lesions or abnormalities noted.

HEENT: Normocephalic, visible bruising left parietal area, tender to palpation. Pupils equal, round, reactive to light and accommodation (PERRLA). No vision changes reported. No nasal discharge or bleeding. Oropharynx clear.

NECK: Full range of motion, no cervical spine tenderness, no nuchal rigidity

Neurological: Alert and oriented x 4. GCS 15/15. Mild resting tremor consistent with Parkinson’s disease. Some bradykinesia noted. Motor strength 4/5 in lower extremities, 5/5 upper extremities. Reflexes 2+ throughout. Balance impaired, requires assistance with ambulation. Coordination testing shows mild difficulty with rapid alternating movements.

Cardiovascular: Regular rate and rhythm, blood pressure within normal limits for age

Respiratory: Clear to auscultation bilaterally, no respiratory distress

Musculoskeletal: Mild rigidity consistent with Parkinson’s disease. Gait slow and shuffling. Postural instability present.

Vital Signs:

• Temperature: 98.8°F
• Blood Pressure: 120/62 (sitting)
• Pulse: 54 (bradycardic)
• Respirations: 20
• SpO2: 96% on room air
• Pain: 3/10 (head pain)

Assessment

General: 72-year-old male in no acute distress, alert and oriented with mild forgetfulness, visible head trauma from fall

Neurological: Demonstrates first-degree heart block with bradycardia. Neurological exam consistent with known Parkinson’s disease. No focal neurological deficits noted post-fall. GCS 15/15. Mild cognitive changes may be related to age and Parkinson’s disease progression.

Cardiovascular: Bradycardic with first-degree heart block, otherwise stable

Safety: High fall risk patient per protocol due to age, Parkinson’s disease, and recent fall with balance difficulties

Differential Diagnoses

Closed Head Injury/Mild Traumatic Brain Injury: Patient presents with fall-related head trauma with visible bruising and mild pain. No loss of consciousness reported, which supports mild TBI classification. Patient maintains normal GCS and no focal neurological deficits, consistent with closed head injury.

Post-Fall Syndrome: Patient with multiple fall risk factors including age >65, Parkinson’s disease, and balance difficulties. Recent fall with concern for future falls and functional decline.

Parkinson’s Disease with Progression: Patient’s wife reports recent changes in ability to complete ADLs, suggesting possible disease progression contributing to increased fall risk and functional decline.

Medication-Related Side Effects: Current medications for Parkinson’s disease can contribute to orthostatic hypotension and balance issues, potentially contributing to fall risk.

Most Likely Diagnosis: Closed head injury (mild traumatic brain injury) secondary to fall in patient with Parkinson’s disease and high fall risk. No evidence of severe TBI given normal GCS, absence of LOC, and stable neurological exam.

Plan

Health Promotion

✓ Fall Prevention Education – Comprehensive education on home safety modifications, use of assistive devices, and balance strategies

✓ Parkinson’s Disease Management – Continue current medication regimen and regular neurology follow-up

✓ Physical Activity – Appropriate exercise program designed for Parkinson’s patients to improve balance and strength

Screening

✓ Neurological Monitoring – Serial neurological assessments q4h x 24 hours to monitor for delayed complications

✓ Cognitive Assessment – Consider formal cognitive screening given mild forgetfulness

✓ Fall Risk Assessment – Comprehensive fall risk evaluation and interventions

Immediate Management

✓ Head CT Scan – To rule out intracranial hemorrhage or other complications

✓ Neurological Monitoring – Frequent neuro checks for 24 hours

✓ Fall Precautions – Implement fall prevention protocols immediately

✓ Pain Management – Appropriate analgesics for head pain

✓ Safety Measures – Bed closer to nurses’ station, call light within reach, assistance with mobility

Long-term Management

✓ Physical Therapy – Evaluation for balance training and fall prevention strategies

✓ Occupational Therapy – Assessment for ADL modifications and home safety

✓ Medication Review – Assess current Parkinson’s medications for optimization ✓ Home Safety Assessment – Environmental modifications to reduce fall risk

✓ Family Education – Teach family members about fall prevention and safety measures

Complete Step-by-Step Guide to Writing the Charles Peterson iHuman Case Study

Completing the Charles Peterson iHuman case requires a systematic approach that mirrors real clinical practice for elderly patients with neurological conditions. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.

Step 1: Pre-Case Preparation and Initial Approach

Before diving into the case, review the doorway information and formulate your initial clinical approach.

Key Information to Note:

• 72-year-old male with “fall and suspected closed head injury”
• History of Parkinson’s disease
• Lives with wife, retired farmer
• Consider immediate priorities: head trauma assessment, neurological evaluation, fall risk factors

Initial Clinical Mindset: Approach this case with neurological conditions and fall risk as your primary considerations. The age, gender, and Parkinson’s history immediately suggest high fall risk requiring systematic neurological evaluation and safety assessment.

Step 2: Conducting the History of Present Illness (HPI)

The HPI is crucial for establishing the foundation of your assessment. Use the OLDCARTS method systematically:

Onset: Ask about when and how the fall occurred

• Key points to elicit: Fell while walking at home, lost balance

Location: Determine the impact site and current pain location

• Target response: Hit left side of head, visible bruising left parietal region

Duration: How long since the fall and duration of symptoms

• Important detail: Fall occurred earlier today, pain constant since fall

Character: Detailed description of symptoms

• Critical descriptor: Constant head pain, no throbbing or severe pain

Aggravating factors: What makes symptoms worse

• Essential findings: Movement may increase pain

Relieving factors: What provides relief

• Key response: Rest, avoiding sudden movements

Timing/Treatment: Pattern and current treatments

• Important pattern: Constant since fall, mild pain level

Severity: Pain scale rating

• Typical response: 3/10 for head pain

Associated Symptoms:

• Ask specifically about: LOC, nausea, vomiting, vision changes, confusion, weakness
• Key findings: Denies LOC, no nausea/vomiting, mild forgetfulness but oriented

Step 3: Review of Systems (ROS)

Conduct a thorough but focused ROS, paying special attention to neurological and related systems:

Neurological:

• Level of consciousness, confusion, memory changes
• Headache, dizziness, vision changes
• Weakness, numbness, coordination problems
• Balance and gait difficulties

Cardiovascular:

• Heart rate and rhythm (noting bradycardia)
• Blood pressure patterns
• Orthostatic symptoms

General:

• Pain levels, fatigue
• Recent functional changes

Step 4: Past Medical History, Social History, and Family History

Past Medical History:

• Parkinson’s disease (most significant)
• Current medications: Carbidopa/Levodopa
• No other significant medical history

Social History:

• Living situation: Lives with wife on family farm
• Occupation: Retired farmer
• Functional status: Recent decline in ADLs per wife
• Safety concerns: High fall risk

Family History:

• May be non-contributory for this acute presentation
• Focus on immediate safety and neurological concerns

Step 5: Physical Examination Strategy

Perform a comprehensive neurological-focused physical exam:

Vital Signs:

• Expected findings: Bradycardia (54 bpm), stable other vitals
• Note: Patient should be monitored for changes

Neurological Examination:

• Mental Status: GCS 15/15, alert and oriented x 4
• Cranial Nerves: PERRLA, no focal deficits
• Motor: Strength testing, note Parkinsonian features
• Sensory: Intact sensation
• Reflexes: Document DTRs
• Coordination: Assess for cerebellar function
• Gait: Note shuffling gait, balance difficulties

Head and Neck:

• Visual inspection: Note bruising in left parietal region
• Palpation: Assess for tenderness, step-offs, hematomas
• Cervical spine: Rule out cervical injury

Step 6: Developing Differential Diagnoses

Propose at least 3-4 appropriate differentials with rationales:

Primary Consideration: Closed Head Injury (Mild TBI)

• Supporting evidence: Fall with head impact, visible trauma, mild pain, no LOC

Secondary Considerations:

• Parkinson’s Disease Progression
  • Rationale: Recent functional decline, increased fall risk
• Post-Fall Syndrome
  • Rationale: High-risk patient with balance difficulties
• Medication-Related Effects
  • Rationale: Parkinson’s medications can affect balance and BP

Step 7: Diagnostic Test Interpretation

Interpret provided test results to support your assessment:

Expected Key Findings:

• Head CT: Rule out intracranial hemorrhage
• Neurological Monitoring: Track for delayed complications
• Cardiac Monitoring: Note bradycardia with first-degree heart block

Clinical Correlation: Use findings to support mild TBI diagnosis and implement appropriate safety measures.

Step 8: Final Diagnosis and Most Significant Active Problem (MSAP)

Primary Diagnosis: Closed Head Injury (Mild Traumatic Brain Injury) secondary to fall

Justification:

• Fall with head impact and visible trauma
• No loss of consciousness
• Normal GCS with mild symptoms
• High fall risk due to Parkinson’s disease

MSAP Selection: Choose “Closed Head Injury” or “Fall Risk” as your Most Significant Active Problem, as this represents the immediate safety concern requiring intervention.

Step 9: Comprehensive Management Plan

Develop a multi-faceted treatment approach:

Immediate Management:

• Neurological monitoring q4h x 24 hours
• Fall precautions implementation
• Head CT scan to rule out complications

Safety Interventions:

• High fall risk protocols
• Environmental modifications
• Assistance with mobility

Medication Management:

• Continue current Parkinson’s medications
• Appropriate pain management for head injury

Rehabilitation Services:

• Physical therapy for balance and fall prevention
• Occupational therapy for ADL assessment
• Home safety evaluation

Follow-up Plan:

• Return visit to monitor neurological status
• Neurology follow-up for Parkinson’s management
• Primary care coordination

Step 10: Documentation and Submission Tips

Writing Your Summary:

• Create a concise summary explaining your clinical reasoning
• Include how you arrived at the problem list
• Cite specific assessment findings and safety concerns
• Use professional medical terminology

Key Documentation Elements:

• Assessment Statement: Brief patient summary with key findings
• Clinical Reasoning: Explain diagnostic thought process
• Evidence Correlation: Link physical findings to fall risk factors
• Management Rationale: Justify safety interventions and monitoring plan

Final Submission Checklist:

• ✓ Complete neurological history with focus on fall circumstances
• ✓ Comprehensive neurological and fall risk physical exam
• ✓ Appropriate differential diagnoses with rationales
• ✓ Correct final diagnosis and MSAP
• ✓ Evidence-based safety and management plan
• ✓ Professional documentation with proper fall risk assessment

Charles Peterson iHuman Case Summary

Grading Criteria

The Charles Peterson iHuman case will evaluate you across several critical domains to ensure comprehensive neurological and fall risk assessment skills. Here’s what you need to focus on to maximize your score:

(1) History Taking (Major Points):

You must ask targeted questions about fall circumstances and neurological symptoms to get full credit. Essential questions include: exact fall mechanism, loss of consciousness assessment, neurological symptoms (headache, nausea, vision changes), Parkinson’s symptom progression, medication compliance, and functional status changes. Don’t miss asking about: previous falls, current balance difficulties, home safety concerns, and ADL independence. The rubric specifically rewards students who ask about pain severity using a 1-10 scale and relationship to neurological symptoms.

(2) Physical Examination (High Weight):

Focus your exam on neurological and fall risk assessment. Must-do components: Glasgow Coma Scale, comprehensive neurological examination, head and neck assessment, balance and gait evaluation, and Parkinson’s-specific assessments (tremor, rigidity, bradykinesia). Pro tip: The rubric awards points for documenting specific neurological findings and fall risk factors – many students forget to assess postural stability and environmental safety needs.

(3) Differential Diagnosis (Critical for Scoring):

You need to propose at least 3 appropriate differentials with brief rationales. Expected differentials include: closed head injury/mild TBI, Parkinson’s disease progression, post-fall syndrome, and medication-related effects. Scoring secret: The rubric rewards students who can distinguish between different types of head injuries and understand the relationship between Parkinson’s disease and fall risk.

(4) Final Diagnosis & MSAP:

You must correctly identify closed head injury with fall risk factors as your Most Significant Active Problem (MSAP). Justification is key – cite the fall mechanism, lack of LOC, visible trauma, and underlying Parkinson’s disease as supporting evidence.

(5) Management Plan (Heavily Weighted):

The rubric expects comprehensive management including: neurological monitoring protocols, fall prevention strategies, safety interventions, and appropriate follow-up care. High-scoring responses mention: specific monitoring frequencies, fall risk protocols, rehabilitation referrals, and medication management considerations.

(6) Patient Safety:

Demonstrate understanding of fall prevention and neurological monitoring. Bonus points for: discussing specific safety modifications, explaining monitoring rationales, and addressing family education needs about fall prevention strategies.

Example of a High-Scoring Clinical Summary

Here’s how a top-performing student might document this case:

Patient Summary – Charles Peterson

Situation: 72-year-old male with Parkinson’s disease presenting with fall-related head injury with visible trauma but no loss of consciousness.

Background: Significant fall risk factors including age >70, Parkinson’s disease with recent functional decline, balance difficulties, and history of losing balance while walking. Currently managed on Carbidopa/Levodopa with wife reporting decreased ADL independence.

Assessment: Physical examination notable for visible left parietal bruising, mild head pain (3/10), stable vital signs with bradycardia, and GCS 15/15. Neurological exam reveals typical Parkinsonian features with no new focal deficits. High fall risk per protocol with impaired balance and postural instability.

Primary Diagnosis: Closed head injury (mild traumatic brain injury) secondary to fall in patient with Parkinson’s disease.

Recommendation:

• Implement immediate fall precautions and safety protocols
• Neurological monitoring q4h x 24 hours to assess for delayed complications
• Head CT scan to rule out intracranial injury
• Physical therapy evaluation for balance training and fall prevention
• Occupational therapy assessment for home safety modifications
• Continue current Parkinson’s medications with close monitoring
• Family education on fall prevention strategies and warning signs
• Follow-up with neurology for Parkinson’s management and primary care for injury monitoring

Patient Education Provided: Explained head injury precautions, importance of neurological monitoring, fall prevention strategies, and clear instructions to report any worsening symptoms including severe headache, vomiting, confusion, or balance changes. Emphasized the importance of home safety modifications and use of assistive devices.

Conclusion

By following this comprehensive approach to the Charles Peterson case, you’ll demonstrate the clinical reasoning skills that iHuman evaluates for complex neurological presentations in elderly patients. Remember, success in neurological cases with fall risk requires systematic thinking: gather detailed history about fall circumstances and functional status, perform focused but thorough neurological examination, consider appropriate differentials including both acute injury and underlying chronic conditions, and develop evidence-based management plans that prioritize patient safety. The key is treating each iHuman simulation as you would a real patient encounter – be thorough, think critically about fall risk factors, and always prioritize neurological monitoring and fall prevention. With this guide, you’re well-prepared to excel in this challenging but rewarding case simulation.

Frequently Asked Questions

What is the correct diagnosis for Charles Peterson’s presentation?

Charles Peterson’s primary diagnosis is closed head injury (mild traumatic brain injury) secondary to fall in a patient with Parkinson’s disease. The key distinguishing features include the fall mechanism with head impact, visible bruising in the left parietal region, mild head pain, absence of loss of consciousness, and maintained Glasgow Coma Scale of 15/15. Students often struggle with determining TBI severity, but remember that mild TBI is characterized by GCS 13-15, brief or no loss of consciousness, and minimal neurological deficits.

What are the critical physical exam components I need to perform to score well?

Essential physical exam elements include Glasgow Coma Scale assessment, comprehensive neurological examination including mental status, cranial nerves, motor and sensory function, and coordination testing. For Parkinson’s-specific assessment, evaluate tremor, rigidity, bradykinesia, and postural stability. Many students miss points by not performing fall risk assessment, balance testing, and home safety evaluation, which are crucial for managing elderly patients with movement disorders.

How do I address the fall risk component in my assessment and plan?

People with Parkinson’s disease have a high risk for falls due to balance issues, walking changes, and postural instability. Your assessment must include comprehensive fall risk evaluation focusing on freezing of gait, reduced gait speed, and prior history of falls as key risk factors. Multimodal and multi-domain fall prevention interventions may be beneficial, including physical therapy, occupational therapy, environmental modifications, and patient/family education.

What management interventions should I include for this case?

The comprehensive management plan should address both immediate head injury monitoring and long-term fall prevention. Include neurological monitoring with serial GCS assessments, typically every 30-60 minutes initially, and head CT scanning to rule out intracranial complications. For fall prevention, implement immediate safety protocols, physical therapy for balance training, occupational therapy for ADL assessment, medication review, and comprehensive patient/family education about fall prevention strategies and warning signs requiring immediate medical attention.