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

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