David, a 42-year old male veteran, presents to Mountain Home VAMC ER for the first time with complaints
of left shoulder pain. David states he has recently moved to this area from Louisville, KY, where he had his
shoulder surgery six months prior. He states that “my shoulder has not been right since the surgery” and
that “OTC drugs do not work at all”. He cannot recall the last use or dosage of Tylenol or any other pain
medications he took. He states “I just took whatever my girlfriend gave me for pain”.
David’s social history includes 2 pack per day cigarette smoking and “a pint of liquor every now and then
to ease the pain”. He denies any illicit drug use. He is currently unemployed and staying with his girlfriend
who lives in the area.
David denies any food or medication allergies. He is up to date on his immunizations. His medical history
includes hypertension, hyperlipidemia, PTSD, and generalized anxiety. Surgical history includes left
rotator cuff repair in 2019.
Medications list: Lisinopril 20 mg once daily, Sertraline 100 mg once daily, Simvastatin 20mg at bedtime
daily,
Melatonin 6 mg at bedtime as needed.
On examination, David is alert and oriented to person, place, time, and situation. He is appropriately
groomed, well-developed, and appears in no acute distress. His vitals signs are as follows: T 97.3, HR 89,
BP 134/81,
RR 18, Sp02 98%, pain 8/10. His weight is 72 kg and height is 179 cm, BMI 22.5. Left shoulder appears
without redness or swelling, the incisions are well-healed and the skin is clean, dry, intact.
Questions:
What is the most likely diagnosis for this patient and why?
What medications would you recommend to this patient for treatment and why?
What tests need to be performed for diagnosis or before starting a treatment regimen?
What are the medical considerations for this patient when deciding on a treatment plan and what changes
would you make because of them?
Sample Solution