HISTORY:
Diffuse joint pain for
Affected joints:
Onset:
Severity: , / 10
Type:
Pattern: , worse during the
Worsening factors:
Treatments tried: ,
, up to °, over
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: -R: , -L: ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Cervical spine: on , range of motion
Shoulder: : on , range of motion
Elbow: : on , range of motion
Wrist: : on , range of motion
Hand: : on , range of motion
Lumbar spine: on , range of motion
Hip: : on , range of motion
Knee: : on , range of motion
Ankle: : on , range of motion
Foot: : on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , ,
- X-ray of affected joints
- MRI of affected joints
- Encourage regular exercise
- Heat or cold therapy
-
-
-
-
- Physical therapy
- Occupational therapy
- Referral to rheumatologist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment