Muscle aches

HISTORY:

Muscle aches for ‍ ‍hoursdays

Location: ‍generalizedlocalized to ‍

Severity: ‍mildmoderatesevere

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍fatigue

‍weakness

‍joint pain

‍swelling

‍redness

‍stiffness

‍headache

‍nausea

‍loss of appetite

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍depression

‍anxiety

‍shortness of breath

‍chest pain



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM



ASSESSMENT:

‍Myalgia due to stress ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍creatinine, ‍electrolytes, ‍LFTs, ‍uric acid, ‍CRP, ‍ESR, ‍CK, ‍TSH, ‍vitamin D, ‍vitamin B12, ‍ferritin, ‍calcium, ‍magnesium, ‍phosphate, ‍albumin

- Urinalysis

- X-ray of the affected area

- Bone scan

- Rest and hydration

- Heat or cold therapy

- ‍Acetaminophen

- ‍NSAIDs

- ‍Muscle relaxants

- Reassess medications that may be causing muscle aches (statins, corticosteroids, aromataze inhibitors)

- Physical therapy

- Massage therapy

- ‍Vitamin D supplement

- ‍Magnesium supplement

- Referral to rheumatologist

- Referral to neurologist

- Follow-up in ‍ ‍weeksmonths

- Return if pain worsens, if new symptoms develop such as weakness or numbness, or if symptoms do not improve with treatment