Diffuse Joint Pain
Age: years old
Gender:
HISTORY:
Presents with a - history of diffuse joint pain
Affected joints:
Onset was
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, up to °, over
, over ,
, , ,
, episodes ,
Contributing factors:
no history of: , , , , , , ,
no use of: , ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: conjunctiva/sclera , lids/lashes , cornea , , extraocular movements , OD 20/, OS 20/
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Skin: on
Extremities: , , cap refill sec, 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: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, viral arthropathy (e.g., parvovirus B19, hepatitis C), reactive arthritis, gout, pseudogout, fibromyalgia, ankylosing spondylitis, inflammatory bowel disease-associated arthritis, Lyme disease, sarcoidosis, hemochromatosis, polymyalgia rheumatica, medication side effect (e.g., aromatase inhibitors, fluoroquinolones), hypothyroidism, hyperparathyroidism, serum sickness, sickle cell disease, leukemia, multiple myeloma, Multiple mecanical pains, stress-related musculoskeletal pain
PLAN:
Investigations:
- Blood work: , , , , , , , ,
- X-ray of affected joints
- MRI of affected joints
Treatments:
- Encourage regular exercise
- Heat or cold therapy
-
-
-
-
- Physical therapy
- Occupational therapy
Further care:
- 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
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: