Problem:
1. What is your provisional diagnosis?
2. What signs and symptoms lead you to this diagnosis?
3. Describe the mechanism that can lead to this condition.
4. How will you address these signs and symptoms in your treatment plan?
5. What kind of common and less common problems need to be excluded?
6. How will the expectation of the patient influence your treatment?
7. Is the patient likely to benefit from referral to other health professionals?
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. Need Assignment Help?