COMPREHENSIVE CASE STUDY CHIEF COMPLAINT SHOULDER PAIN
History of Present Illness A 26-year-old male firefighter presents to his PCP following an ED visit for an episode of dehydration and severe muscle pain experienced during rigorous physical activity. Yesterday, he fought a fire for an extended period under extreme physical conditions. Despite consuming significant amounts of water, he began feeling lightheaded, experienced severe pain in his calves and shoulders, and noticed dark-colored urine. He was evaluated in the ED and discharged with instructions to hydrate. However, he continues to have dark-colored urine, generalized muscle pain, and fatigue. He reports feeling “like I’ve been hit by a truck.”
Review of Systems (ROS) Positive: Weakness, exhaustion, palpitations, shortness of breath, nausea, dark-colored urine, muscle pain (shoulders, lower back, calves). Negative: Diarrhea, constipation, anuria, hematuria, muscle weakness, numbness, tingling.
Past Medical History: Recurrent musculoskeletal injuries (shoulder, knee), HTN, and anxiety.
Social History: Moderate alcohol use (occasional beer), no tobacco or drug use. Unmarried in a casual relationship with no children. Active lifestyle
Family History: Mother with breast cancer (remission), father without chronic conditions. Sibling brother with Hx chronic migraines
Allergies: None.
Medications: Ibuprofen 200mg PO q 8 hrs PRN muscle aches, Lisinopril 2.5mg PO daily, Lexapro 10mg PO daily.
Physical Examination
Vitals: T 37.3°C (99.1°F), P 96BPM, RR 12 BPM, BP 134/86, BMI 29.7.
General: A&O; no acute distress; overweight.
Skin: No erythema, pallor, or abnormalities noted.
HEENT: Normal findings.
Lungs: Vesicular breath sounds throughout, equal bilaterally.
Cardiac: Regular rate and rhythm, no murmurs/rubs/gallops.
Abdomen: Soft, mild epigastric tenderness, bilateral flank tenderness, no CVA tenderness.
Musculoskeletal: Tenderness over bilateral shoulders, reduced ROM due to pain, generalized tenderness of calves and quadriceps, severe paralumbar tenderness with guarding and hypertonicity.
Neurological: A&O×3; cranial nerves intact.
CLINICAL DISCUSSION
Based on the subjective and objective information presented, select and prioritize three differential diagnoses, including each diagnosis’s rationale, pathophysiology, and pertinent positives and negatives.
For the working diagnosis, explain why this is the primary diagnosis, what physical findings support the primary diagnosis, and list any additional body systems not addressed in the physical exam and how those physical findings could further support your primary diagnosis.
· List any additional questions you may have inquired about in your history taking that have not already been presented in the HPI and are necessary to establish your diagnosis.
· Address any necessary laboratory or diagnostic testing and the clinical significance of these diagnostics for your diagnosis or ultimate treatment plan.
· Discuss the next appropriate steps in your management and at least two potential complications of this diagnosis untreated.
· Finally, discuss medication management, including pharmacologic and nonpharmacologic choices with appropriate dosing, comprehensive patient education, and follow-up recommendations.
Recall the necessary components in your case studies from NUR631. We will continue to build on the format throughout the clinical aspect of adulthood.
APA format with at least FIVE peer-reviewed references to support diagnosis, management, and patient education.
APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2019-2024 only. (Within the last five years)
Please do not solely use a website as your scholarly reference. While it is fine to use it as a supplement, a journal article or text should be referenced.
Please use North American peer-reviewed journals
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