Reference no: EM133858776

Question

Journal Details 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.