HISTORY:
Muscle aches for
Location:
Severity:
Worsening factors:
Treatments tried: ,
, up to °, over
, over ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , , , , ,
- Urinalysis
- X-ray of the affected area
- Bone scan
- Rest and hydration
- Heat or cold therapy
-
-
-
- Reassess medications that may be causing muscle aches (statins, corticosteroids, aromataze inhibitors)
- Physical therapy
- Massage therapy
-
-
- Referral to rheumatologist
- Referral to neurologist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as weakness or numbness, or if symptoms do not improve with treatment