CASE STUDY 5

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 COMPREHENSIVE CASE STUDY – CHIEF COMPLAINT – SHOULDER PAIN 

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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,

DO NOT use any European Journal

Please use reliable medical references such as the Current Medical Diagnosis and Treatment book or UpToDate. Do not use WebMD, Wikipedia, etc., as these are not advanced practice references.  

APA format (if using outside sources).

Criterion

Exemplary (Full Points)

Proficient

Satisfactory

Needs Improvement

Unsatisfactory

Differential Diagnosis Development and Justification (30 Points)

30–26 Points: Identifies three well-prioritized differential diagnoses with clear and accurate rationale. Pathophysiology is detailed and evidence-based. Pertinent positives and negatives are comprehensive and clearly linked to the clinical presentation.

25–21 Points: Identifies three differential diagnoses with adequate rationale and pathophysiology. Pertinent positives and negatives are mostly accurate but may lack depth or clarity.

20–16 Points: Identifies three differential diagnoses but with limited rationale or incomplete pathophysiology. Pertinent findings are minimally addressed or lack depth.

15–11 Points: Fewer than three differential diagnoses, or rationale and pathophysiology are unclear or incorrect. Pertinent findings are not fully addressed.

10–0 Points: Little to no effort to develop differential diagnoses, rationale, or supporting findings.

Working Diagnosis and Supporting Evidence (20 Points)

20–18 Points: Working diagnosis is logically prioritized and strongly supported with clinical evidence. Additional body systems and findings are identified and well-justified.

17–15 Points: Working diagnosis is clearly identified and supported by evidence, though explanation of additional systems or findings may lack depth or specificity.

14–12 Points: Working diagnosis is identified but lacks a thorough explanation or fails to integrate key clinical evidence. Additional systems are mentioned but minimally explained.

11–8 Points: Working diagnosis is unclear or poorly supported by clinical evidence. Additional systems are not addressed or lack rationale.

7–0 Points: Working diagnosis is absent or unsupported by clinical reasoning.

History, Diagnostic Testing, and Relevance (20 Points)

20–18 Points: Comprehensive history questions are identified, relevant to the case, and explained thoroughly. Diagnostic testing choices are appropriate and well-rationalized, with clear connections to the diagnosis and management.

17–15 Points: History questions and diagnostics are mostly appropriate and relevant, though some explanations or connections to the case may be incomplete.

14–12 Points: History and diagnostics are partially appropriate but lack depth or connection to the diagnosis and management.

11–8 Points: History and diagnostics are incomplete or minimally relevant, with little explanation of their significance.

7–0 Points: Few or no relevant history questions or diagnostic tests are identified.

Management Plan and Complications (20 Points)

20–18 Points: Comprehensive management plan includes pharmacologic and non-pharmacologic treatments with appropriate dosing and monitoring. Potential complications of untreated diagnosis are well-described and clinically relevant.

17–15 Points: Management plan addresses most key elements but may lack depth or specificity in treatment choices or complication discussion.

14–12 Points: Management plan includes some key elements but lacks clarity or thoroughness in treatment options or addressing complications.

11–8 Points: Management plan is incomplete or poorly justified. Complications are minimally addressed or not relevant.

7–0 Points: Management plan is absent or not relevant to the case.

Patient Education and Follow-Up (10 Points)

10 Points: Comprehensive patient education addresses lifestyle changes, medication use, and symptom monitoring. Follow-up recommendations are detailed and appropriately prioritized.

9–8 Points: Patient education and follow-up are thorough, though some aspects of lifestyle or symptom management may lack detail.

7–6 Points: Patient education and follow-up are included but lack depth or specificity in addressing lifestyle or treatment adherence.

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