This journal assignment will demonstrate your ability to prepare a consistent approach to the evaluation and development of a treatment plan for illnesses and conditions in the primary care setting in collaboration with the health care team.
Patient Case: Mr. S
Chief Complaint
“Shoulder pain.”
History of Present Illness
A 48-year-old previously healthy, right-hand-dominant male presents with acute onset 8/10, deep, throbbing, non-radiating, right anterior shoulder pain for days. He denies trauma, history of same, lancinating pain, swelling, extremity weakness, and numbness/tingling. He reports he works as a firefighter and he recently participated in training exercises where he repeatedly “threw Molotov cocktails.” He states he has been using ice and OTC ibuprofen every 8 hours without relief.
Review of Systems
The patient’s ROS is positive for right shoulder pain. The ROS is negative for fever, skin changes/redness/bruising, joint pain, numbness, tingling, weakness, swelling, and trauma.
Relevant History
The patient’s medical history is significant for hypertension (diagnosed age 43), currently controlled on HCTZ as well as chronic low back pain s/p L4/5 fusion (age 47). His social history includes occasional alcohol and marijuana use. He eats a balanced vegetarian diet and exercises for an hour daily. He is married with one son. His family history is positive for hypertension and hyperlipidemia in his father. His mother is well and healthy.
Allergies: Penicillin (hives); no known food allergies.
Medications
25 mg HCTZ daily
OTC ibuprofen 200 mg 2 tablets q8h PRN
Physical Examination
Vitals: T 37.0°C (98.6°F), P 88, R 18, BP 138/92, HT 173 cm (68 in), WT 76.2 kg (168 lbs), BMI 25.7
General: Alert, no acute distress, non-toxic appearing.
Skin, Hair, and Nails: Right upper extremity: intact, no erythema, no ecchymosis, no abrasions/skin breakdown.
Head: Normocephalic, atraumatic.
Neck: FROM, no midline tenderness.
Lungs: Clear to auscultation bilaterally.
Heart: RRR, no murmurs, rubs, or gallops, radial pulse intact bilaterally, capillary refill <2 seconds.
Musculoskeletal: Right upper extremity: LROM to flexion, extension, internal and external rotation at shoulder due to pain, tender to palpation to anterior shoulder over insertion of long head of biceps, positive empty can test, negative cross-over test, no deformity, negative Hawkins, negative Neer, negative Apprehension test, 5/5 grip strength, no arm drop.
Neurologic: Sensation grossly intact to upper extremities.
Journal Assignment:
What is your provisional diagnosis?
What signs and symptoms lead you to this diagnosis?
Describe the mechanism that can lead to this condition.
How will you address these signs and symptoms in your treatment plan?
What kind of common and less common problems need to be excluded?
How will the expectation of the patient influence your treatment?
Is the patient likely to benefit from referral to other health professionals?
