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Myalgia 1
Clinical Reasoning: Myalgia
Jennifer Pineiro
University of Akron
3/24/13
Adult Gerontological NP IV Practicum 8200:631:801-803
Valerie Sisson, MSN, ACNP
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This patient is a 43 year old African American female. Her height is 5ft 6in, weight
96.36kg, BMI 34.2. This Internal Medicine office visit is her first at this site and she is
establishing with a new primary care physician. Her chief complaint is generalized pain and she
is expressing concern that her blood pressure may be elevated. This clinical reasoning paper will
focus on myalgia and the differential diagnoses which apply, followed by a post hoc analysis of
the transpired events. A complete data set, including a detailed SOAP note and a history and
physical exam are included in Appendix A.
Patient History
This patient presents to establish care with a new primary care physician.
She had been under the regular care of physician as well as an OBGYN until 6 months ago when
she lost her insurance. She reports a medical history of hypertension (HTN). She states this was
diagnosed approximately one year ago but refused medical treatment at that time. She states she
intended to begin regular exercise and diet changes to treat her blood pressure but did not start
these. She was prescribed hydrochlorothiazide (HCTZ) 6 months ago, she is unsure of the dose.
She states she took it for 2 months than stopped it on her own due to side effects. She suspected
that the medicine was exacerbating body aches and pains. She denies prior history of diabetes or
high cholesterol. She states her last blood test was one year ago. There is no lab or diagnostic
data available in the computer system. She smokes cigarettes ½ ppd for 20 years. She denies
alcohol use or illicit drug use. She is obese per her current BMI of 34.2.
Her surgical history includes C-Section x2. Her family history is significant for SLE, DM
and HTN in her mother, her father’s medical history is unknown. She has 2 brothers, both are
living, one has DM, the other is healthy. She has 2 children whom are healthy. She is single. She
is currently working part time as a secretary. In terms of health maintenance, she states her last
mammogram and Pap test were in the Fall. She denies either being abnormal in the past.
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History of Present Illness
This is a 43 year old African American female with a history of HTN and cigarette
smoking. She presents today for a routine physical exam and to establish with a new primary
care provider. Her chief complaint today is muscle aches. She states her entire body is sore,
initially described as joint aches, adding that her entire body is sore to touch, she points to her
forearms and shoulders. Stating “just to touch me it hurts.” The symptoms began over one year
ago, possibly two years; she assumed she had the start of arthritis and possibly menopause. She
states the symptoms began to worsen approximately 6 months ago around the time she started
taking HCTZ for her blood pressure. She continued the medicine for 2 months than stopped it on
her own. The muscle aches continued. She states the symptoms are worse in the morning, states
she can hardly get out of bed upon waking described as pain from her shoulders to her heels, she
feels “exhausted” although denies difficulty sleeping. States the pain is bilateral, affecting all
areas and repeatedly talks of pain in her shoulders, forearms and legs. She denies stiff joints, no
joint swelling or redness. She states she has taken Motrin and her boyfriend’s Ultram in the past
with minimal relief. She denies prior evaluation by a rheumatologist.
Physical Examination
General: This is an obese African American female. Her height is 5 feet, 6 inches, weight
96.36kg, BMI 34.2. Her Vital signs include BP 148/98, HR 74, RR 20, T 36.6. She is in no
acute distress, alert and cooperative, talkative, making appropriate eye contact, oriented x4.
HEENT: Head is normocephalic. Eyes: Pupils are equal and reactive to light. Sclera and
conjunctiva are clear, white, without exudate Ears: Bilateral TMs are normal. The oropharynx
appears pink and moist, without erythema or exudate, tonsils of normal size. Dentition appears in
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good condition. Gingiva appears healthy, pink and moist Neck: supple. Trachea midline. No
lymphadenopathy on palpation. No palpable thyroid enlargement, asymmetry, mass or nodules.
Heart: normal S1, S1, regular rhythm and rate, no murmur noted, no JVD, no carotid bruit
Lungs: Lungs are clear all lobes. No crackles or wheeze. Slightly diminished bases.
Abdomen: soft, obese, non-distended, non-tender, with active bowel sounds. No hepatomegaly
or splenomegaly on palpation
Extremities: no edema, palpable pulses 2+ bilaterally, warm to touch
Musculoskeletal: Upper and lower extremity strength 5/5 bilaterally, full active ROM present, no
joint swelling or redness noted, no joint pain elicited with palpation. Fingers joints without bony
prominences. Light palpation of the soft tissue elicits pain and guarding in the areas of the upper
back, upper chest, shoulders, upper and lower arms, hips and thighs.
Neurological: Cranial nerves 1-XII intact, Motor and sensory exam of the upper and lower
extremities is normal. DTRs graded 2+ bilaterally and symmetrical
Skin: No rash or redness, no swelling, dry in general
Differential Diagnoses
The differential diagnoses that will be investigated for this patient include Fibromyalgia,
polymyalgia rheumatica (PMR), rheumatoid arthritis (RA), systemic lupus erythematous (SLE),
and hypothyroidism.
Fibromyalgia is a syndrome “characterized by symptoms of widespread musculoskeletal
pain, fatigue, non-restorative sleep, depression, headaches and gastrointestinal complaints”
(Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2008, p.948). According to the American College
of Rheumatology (1990) Criteria for the Classification of Fibromyalgia, both of the following
criteria must be met for a Fibromyalgia diagnosis: widespread pain for at least three months and
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pain in 11 of 18 tender point sites on digital palpation. Widespread pain is defined as “pain in the
left side of the body, pain in the right side of the body, pain above the waist, and pain below the
waist,” and “axial skeletal pain” (Wolfe, Smythe, Yunus, Bennett, Bombardier,
Goldenberg,….Sheon, 1990, p.171). In regards to the tender points, the specific sites are bilateral
in the following areas: occiput, low cervical, trapezius, supraspinatus, second rib, lateral
epicondyle, gluteal, greater trochanter, and knee. For the tender point to be considered positive,
the patient must complain of pain at the site after digital palpation by the examiner using 4kg of
force (Wolfe et al., 1990). A patient description of “pain all over” is considered a “powerful
discriminatory symptom” for diagnosis (Wolfe et al., 1990, p.170).
According to Buttaro et al. (2008), physical exam findings of a patient with fibromyalgia
will include normal muscle strength, lack of joint or soft tissue inflammation and no evidence of
an anatomic lesion to explain the musculoskeletal pain. Although diagnosis is based heavily on
history and physical exam alone, diagnostics can be used to rule out differential diagnoses.
Complete blood count (CBC), rheumatoid factor (RF), anti-nuclear antibodies (ANA),
erythrocyte sedimentation rate (ESR), thyroid stimulating hormone (TSH) and electromyography
will be normal in these patients (Buttaro et al., 2008).
Rheumatoid arthritis (RA) is the second differential considered in this patient.
“Rheumatoid arthritis is an autoimmune disorder characterized by symmetric inflammatory
polyarthritis and varying degrees of extra-articular involvement” (Buttaro et al., 2008, p. 1248).
RA effects women more than men and the risk increases with age. The cause is unknown but
genetics, hormones, environment (specifically smoking) and reproductive factors are all
suspected to play a role (Buttaro et al., 2008).
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RA can be defined by the 1987 American College of Rheumatology (ACR) classification
criteria. In 2010, the ACR and the European League Against Rheumatism (EULAR) added to
this classification criteria to assist with diagnosis of patients at earlier stages of the disease. “This
new classification system redefines the current paradigm of RA by focusing on features at earlier
stages of disease that are associated with persistent and/or erosive disease, rather than defining
the disease by its late-stage features” (Aletaha, Tuhina, Silman, Funovits, Felson, Bingham,
…Hawker, 2010, p. 2570). The hope is that earlier diagnosis and treatment can prevent or
minimize the long term effects of the disease process. The new criteria are designated for newly
presenting patients and eligibility requires clinical synovitis in at least one joint. This is
described as a swollen or tender joint on exam but excludes the distal interphalangeal joints, first
carpometacarpal joints, and first metatarsophalangeal joints (Aletaha et al., 2010). In this new
criteria, the diagnosis of RA is based on “the confirmed presence of synovitis in at least 1 joint,
absence of an alternative diagnosis that better explains the synovitis, and achievement of a total
score of 6 or greater (of a possible 10) from the individual scores in 4 domains: number and site
of involved joints (score range 0–5), serologic abnormality (score range 0–3), elevated acutephase response (score range 0–1), and symptom duration (2 levels; range 0–1)” (Aletaha et al.,
2010, p. 2570). The serological abnormalities listed include the anti-citrullinated protein
antibody (ACPA) and IgM-rheumatoid factor (RF) levels and the acute phase response is based
on serum C-Reactive protein (CRP) and ESR. The duration of symptoms is taken from the
patients self-description of pain, swelling and tenderness of any joint at the time of assessment
with less than six weeks scoring a zero and more than six weeks one point (Aletaha et al., 2010).
Interestingly, symmetry of joint symptoms is not a feature of these new criteria “since it did not
carry an independent weight in any phase of the work” (Aletaha et al., 2010, p. 2578).
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Buttaro et al. (2008) describes the onset of RA as “insidious” usually occurring over
weeks or months (p. 1248). The initial symptoms often include systemic complaints of
“weakness, weight loss, malaise, fatigue, anorexia, aching and stiffness (Buttaro et al., 2008, p.
1248). Complaints of painful, swollen joints are bilateral and symmetric and morning stiffness
can last up to 2 hours (Buttaro et al., 2008). Although diagnosis is based heavily on history and
physical exam, according to Buttaro et al. (2008), additional diagnostic tests to those mentioned
by the ACR, include a baseline CBC, hepatic panel, creatinine and urinalysis. Normochromic
anemia is common in patients with RA. Regarding serum RF, this usually becomes positive
during the course of the disease but may be normal at the onset. X-Rays of the hands, feet and
other affected joints may show bony erosions and these diagnostics are used as a baseline for
treatment, a reference for future evaluation and are used to assist with diagnosis (Buttaro et al.,
2008).
PMR is a “musculoskeletal syndrome,” “characterized by pain and stiffness in the neck,
shoulder girdle, and pelvic girdle; an elevated ESR and an elevated CRP; and a dramatic, rapid
response to corticosteroids” (Buttaro et al., 2008, p. 1241). According to the Cleveland Clinic
Journal of Medicine, “polymyalgia rheumatica should be considered in the differential diagnosis
in patients over 50 years old who present with bilateral achiness and stiffness in the shoulders or
hips or both” (Mandell, 2004, p. 489). The hallmark features of PMR include age over 50,
proximal pain and stiffness, nighttime and morning worsening, normal strength and systemic
symptoms which may include fatigue, weight loss, fever, and sweats. Unusual symptoms may
include carpal tunnel syndrome, distal swelling, peripheral synovitis and asymmetric pain
(Mandell, 2004). The pain of PMR is diffuse, limits mobility and causes difficulty rising from a
chair with gelling after immobility (Buttaro et al., 2008). PMR often overlaps with the condition
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of giant cell arteritis (GCA) and GCA is the most common complication of PMR (Mandell,
2004). The cause of PMR is unknown but genetic factors and infectious triggers are suspected
(Mandell, 2004).
Patients with PMR often have a normal joint examination with normal range of motion of
the hips and shoulders. Although they may present with joint and muscle tenderness, there is
usually no loss of joint motion, muscle atrophy or muscle weakness. These patients should be
assessed for Giant Cell Arteritis and this includes evaluation of the temporal artery for normal
pulsation and the presence of enlarged, erythematous or tender vessels (Buttaro et al., 2008).
Diagnostic tests should include CBC, ESR, CRP, LFT, RF, creatinine phosphokinase, ANA,
TSH and serum electrophoresis (Buttaro et al., 2008). “Most patients with PMR have an elevated
ESR above 40 to 50mm/hr, and many have ESRs above 80mm/hr” (Buttaro et al., 2008, p.
1242). These patients also may have an elevated CRP, normocytic anemia and mildly elevated
LFTs with normal RF and ANAs. Additional diagnostic tests may include nerve conduction
studies and muscle biopsy, both of which are normal with PMR (Buttaro et al., 2008).
Systemic Lupus Ertythematous (SLE) is a “chronic multisystem inflammatory rheumatic
disease that may cause diverse symptoms such as fatigue, joint pain, skin rashes, seizures, edema
and chest pain” (Buttaro et al., 2008, p. 1252). The pathogenesis includes the development of
antibodies against tissues in the cell nuclei. The cause is unknown with genetics and environment
suspected to play a role. It is more common in women, with higher incidences in African
American women and those of childbearing age (Buttaro et al., 2008). The clinical presentation
varies and can appear as relapses and remissions of mild symptoms such as fatigue, arthralgia
and skin rashes or with acute onset with more severe manifestations such as nephritis or
vasculitis (Buttaro et al., 2008). “The malar skin rash, one of the most recognizable features of
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SLE, is observed in only 35% of patients” (Buttaro et al., 2008, p. 1253). “Approximately one
third of SLE patients will experience Raynauds phenomenon” (p. 1254). Patients with active
disease may have anorexia, weight loss, fever, lymphadenopathy, tachycardia and anemia
(Buttaro et al., 2008).
The 1997 update to the 1982 American College of Rheumatology Criteria for the
Classification of SLE states that four of the following eleven must be present serially or
simultaneously for the diagnosis of SLE: malar rash, discoid rash, photosensitivity, oral ulcers,
nonerosive arthritis (involving two or more peripheral joints), pleuritic or pericarditis, renal
disorder (proteinuria or cellular casts), neurological disorder (seizures or psychosis), hematologic
disorder (hemolytic anemia, leukopenia, lyphopenia or thrombocytopenia), immunologic
disorder (Anti-DNA, Anti-Sm, or positive anti-phospholipid antibody), and positive ANA
(Hochberg, 1997).
Diagnostic tests for SLE include urinalysis, CBC, BUN, creatinine, ESR, RF, CRP, Total
ANA, Serum gamma globulins, Anti-double stranded DNA (dsDNA), anti-Smith (anti-Sm), antiRo, anti-La, antiribonucleoprotein, C3, C4, PT/PTT, lupus anticoagulant, anticardiolipin
antibodies (immunoglobulins IgG and IgM). The total ANA test is the most sensitive test but
lacks specificity for SLE, whereas the anti-Sm anti-dsDNA are more specific but less sensitive.
Skin biopsy may show IgG, IgM, IgA, C3 or Clq deposits (Buttaro et al., 2008).
Hypothyroidism is considered in this patient with generalized muscle aches.
“Hypothyroidism is a condition resulting from synthesis of thyroid hormone that is insufficient
to meet bodily needs” (Buttaro et al., 2008, p. 1173). It is the most common disorder of the
thyroid gland is most commonly caused by chronic autoimmune thyroiditis. It occurs more
commonly in women and the risk increases with age. Other risk factors include radiation for
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head and neck cancers, inappropriate dietary intake of iodides, familial tendency, drugs with
anti-thyroid action such as lithium, amiodarone, iodine and radiographic contrast and it may
present transiently after an infection or during the post-partum course (Buttaro et al., 2008).
According to UpToDate, the clinical signs of hypothyroidism can vary depending on the
age at onset and the duration and severity of the deficiency (Ross, 2013). “Common symptoms
of thyroid hormone deficiency include fatigue, cold intolerance, weight gain, constipation, dry
skin, myalgia, and menstrual irregularities” (Ross, 2013, n.p.). “Physical examination findings
may include goiter, bradycardia, hypertension, and a delayed relaxation phase of the deep tendon
reflexes” (Ross, 2013, n.p.). UpToDate recommends screening for hypothyroidism for all
patients with symptoms, risk factors and for those with lab or radiologic abnormalities that could
be caused by hypothyroidism. These include hyperlipidemia, hyponatremia, elevated creatinine
kinase, macrocytic anemia, pericardial or pleural effusions, pituitary or hypothalamic disorders
and autoimmune disorders (Ross, 2013). Diagnosis is based primarily on lab tests. Primary
hypothyroidism is the most common form and is characterized by high TSH (greater than 5) and
low serum T4. Patients with subclinical hypothyroidism may have elevated TSH and a normal
serum T4. Central hypothyroidism is less common and is characterized by a TSH that is not
appropriately elevated and a low serum T4 (Ross, 2013).
Plan For Care
Myalgia (729.1)
-Start Amitriptyline 25mg po qHS
-CBC, CMP, TSH, CRP, ESR, RF, ANA
Depression (311)
-Start Prozac 20mg po once daily
-Counseling services offered. Refused at this time, states she will think about it
HTN (401.9)
-Start Lisinopril 10mg once daily.
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-Advised home Bp monitoring 2-3 times weekly, record on a log and bring to next ov
-DASH diet
Tobacco Use Disorder (305.1)
-Advised cessation, discussed options to assist. Refusing, states is not emotionally ready
Obesity (278)
-Encouraged weight loss. DASH diet.
-Advised 30mins of exercise daily as recommended by the AHA
Request records from prior PCP
Follow up in 2 weeks.
This patient complains of generalized, bilateral muscle aches accompanied by fatigue and
depression. She has no weakness on exam and no clinical signs of joint inflammation. Light
palpation of the soft tissue elicits pain and guarding in the areas of the upper back, upper chest,
shoulders, upper and lower arms, hips and thighs. Her symptoms are bilateral and worse in the
morning. Her pain is not localized to the joints but to the muscle and the soft tissue.
Fibromyalgia is the most likely diagnosis for this patient. She was treated for fibromyalgia with
amitriptyline and for depression with Prozac. Multiple labs were ordered which will help to
exclude other diagnoses.
Looking back, this patient has more symptoms than realized that can be attributed to
hypothyroidism. These include muscle aches, fatigue, weight gain, menstrual irregularities and
hypertension. RA is unlikely because she did not have swollen or tender joints on exam. SLE is
unlikely for similar reasons. Although her labs are pending, she will not likely meet the
diagnostic criteria for SLE because she lacks specific joint pain. This patient is under the age of
50 which makes PMR less likely and her pain is not limited to proximal areas.
This patient is advised follow up in 2 weeks. At that time her symptoms will be reevaluated, her lab tests reviewed and her compliance and tolerance to the new medications will
be assessed. She was started on a tricyclic anti-depressant (TCA) and selective serotonin
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reuptake inhibitor (SSRI) last visit and when used together these increase the risk of serotonin
syndrome and TCA toxicity (FDA, 2013). The patient will be evaluated for sedation, dry mouth,
blurred vision, constipation, urinary retention, altered consciousness, confusion, ataxia,
shivering, pupillary dilation, diarrhea, HTN and diaphoresis (FDA, 2013). The labs that were
ordered should assist with ruling out most of the above differential diagnoses. The patient may
require a Rheumatology referral if her labs are positive for an autoimmune disorder or if they are
negative but her symptoms have not shown any improvement. Her depression will be reevaluated and she will again be assessed for thoughts of harming herself or others. The Prozac
will be discussed and it will be explained that it can take up to 4 weeks to reach full effect.
Counseling will be offered. If her depression has not improved or if she expresses any unstable
signs, she will be referred to a psychiatrist. Her blood pressure and tolerance to lisinopril will be
evaluated. Hopefully she will have blood pressure logs from home to review and she is within
her goal of less than 140/90.
Assuming her blood pressure is stable; she will be advised to follow up in 2-3 months for
a complete physical exam. At that time, her health maintenance issues will be addressed and she
will be evaluated for target organ damage of HTN. She will also be questioned regarding her risk
of sleep apnea given her history of obesity, fatigue, and HTN and she will also be screened for
diabetes and hyperlipidemia.
Primary prevention specific to fibromyalgia might include treatment of anxiety and
depression, and encouragement of regular exercise. Secondary prevention includes evaluation of
personal and family history of chronic pain, evaluation of tender points on musculoskeletal
exam, and the assessment of fatigue and poor sleep complaints. Tertiary prevention of
fibromyalgia would focus on pain management, optimization of functioning and support groups.
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Critique
Neither myself or my preceptor included a specific assessment for trigger points on
our physical exam. We did not draw a creatinine kinase (CK) which may have been helpful. I
would have drawn a Vitamin D level but my preceptor does not usually include these. This
patient was started on three new medications at one office visit. Personally, I would be hesitant
to do this. However, with further research into the treatment of fibromyalgia, it was found that
TCA’s, specifically Amitriptylline 25-50mg, and SSRI’s, specifically Prozac, are often used
together and have been shown to be more effective than either agent when used alone
(Chakrabarty & Zoorob, 2007). Looking back we should have encouraged exercise, stretching,
yoga, etc. in combination with the medications. This was a patient who did not tolerate HCTZ in
the past and stopped it on her own. I wanted to spend a few more minutes with the patient to
discuss fibromyalgia, to educate her on the new medications, to encourage her to give them the
time they require to take effect but time did not allow. I was able to quickly print patient
education handouts from UpToDate for her.
Further Study
A research question for fibromyalgia would be: What is the effect of Vitamin
D supplementation on patients with Fibromyalgia and concomitant Vitamin D deficiency? My
preceptor has made it clear that he does not draw Vitamin D levels on his patients. He prefers to
advise his patients who have concerns for their Vitamin D level to take a 1000U daily
supplement. I am interested in the implications of Vitamin D deficiency on Fibromyalgia.
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References
Aletaha, D., Tuhina N., Silman, A.J., Funovits, J., Felson, D.T., Bingham, C.O., …Hawker, G.
(2010). 2010 Rheumatoid Arthritis Classification Criteria. An American College of
Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis
and Rheumatism, 62(9), 2569-2581. DOI 10.1002/art.27584.
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2008). Primary Care: A
Collaborative Practice (3rd ed.). St. Louis: Mosby.
Chakrabaarty, S. & Zoorob, R. (2007). Fibromylagia. American Family Physician, 76(2), 247254. Retrieved from http://www.aafp.org/afp/2007/0715/p247.html.
Food and Drug Administration (FDA). 2013. Drug Interactions Between Elavil and Prozac.
Retrieved from www.drugs.com.
Hochberg, M.C. (1997). Updating the American College of Rheumatology Revised Criteria for
Classification of Systemic Lupus Erythematosus. Arthritis and Rheumatism, 40(9).
American College of Rheumatology. DOI: 10.1002/art.1780400928.
Mandell, B. (2004). Polymyalgia rheumatica: Clinical presentation is key to diagnosis and
treatment. Cleveland Clinic Journal of Medicine, 71(6), 489-495. DOI
10.3949/ccjm.71.6.489.
Ross, D. (2013). Diagnosis and Screening for Hypothyroidism. Retrieved from
www.uptodate.com.
Wolfe, F., Smythe, H., Yunus, M., Bennett, R., Bombardier, C., Goldenberg, D….Sheon, R.
(1990). The American College of Rheumatology 1990 Criteria For the Classification of
Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism,
33(2), 160-172. The American College of Rheumatology. Retrieved from
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References
http://www.rheumatology.org/practice/clinical/classification/fibromyalgia/1990_Criteria_
for_Classification_Fibro
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Appendix A
Chief Complaint: Muscle aches
HPI: This patient presents to establish care with a new PCP and for a physical exam. She also
has a chief complaint of muscle aches. She reports a medical history of HTN, she also smokes
cigarettes. She currently takes no prescribed medications and takes a multivitamin daily.
In regards to her muscle aches she states her entire body is sore, initially described as
joint aches, adding that her entire body is sore to touch, she points to her forearms and shoulders.
Stating “just to touch me it hurts.” The symptoms began over one year ago, possibly two years,
she assumed she had the start of arthritis and possibly menopause. She states the symptoms
began to worsen approximately 6 months ago around the time she started taking HCTZ for her
blood pressure. She continued the medicine for 2 months than stopped it on her own. The muscle
aches continued. She states the symptoms are worse in the morning, states she can hardly get out
of bed upon waking described as painful from the shoulders to heels, she feels “exhausted”
although denies difficulty sleeping. States the pain is bilateral, affecting all areas and repeatedly
talks of pain in her shoulders, forearms and legs. She denies stiff joints, no joint swelling or
redness. She states she has taken motrin and her boyfriends ultram in the past with minimal
relief. She denies prior evaluation by a rheumatologist.
Allergies: PCN, dust
Medications: Multivitamin
Past Medical History:
HTN, diagnosed 1 year ago per patient. Treated with HCTZ, stopped on her own after 2 months,
thought it was causing muscle aches
Obesity
Cigarette Smoking 1/2ppd x 20 years
Health Maintenance:
PAP-Fall 2012 (University Hospital)
Mammogram-Fall 2012
Influenza vaccine-9/2013
Tetanus booster-2008
Past Surgical History:
C/Section x2
Past Family History:
Mother-living age 69, HTN, DM, SLE
Father-unknown
Brother-living age 52, DM
Brother-living age 48, healthy
Social History:
Employed part time, secretarial work
Single, lives with boyfriend of 8 years
Cigarette smoking ½ ppd x 20years
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Denies alcohol use.
Denies current or prior illicit drug use.
No regular exercise.
ROS
General: Denies anorexia or weight loss. Reports weight gain of 10 pounds in the past year. No
recent illness, fever. She complains of fatigue.
HEENT: Denies recent change in vision or hearing. States last eye exam was two years ago.
States has a dental exam scheduled for the end of the month. She is unsure if she snores. Her
significant other strongly states that the patient does snore but he has not witnessed apneic
periods. Denies headaches.
Cardiovascular: History of HTN. Diagnosed 6 months ago, treated with HCTZ, unsure of the
dose. States stopped it on her own, she thought it was causing muscle aches but states the muscle
aches continued after stopping the medicine. Denies chest pain, palpitations or leg swelling.
Denies prior evaluation by a cardiologist or cardiac testing. She is suspecting that her blood
pressure is elevated since she has been off of her medication.
Respiratory: Denies shortness of breath or cough. No history of asthma.
Gastrointestinal: Denies abdominal pain, nausea, constipation or diarrhea. Denies recent change
in her bowels. No history of reflux. No prior abdominal surgeries besides C-Section.
Genitourinary: Denies difficulty urinating. No dysuria, frequency or incontinence.
GYN: Reports irregular menses, unpredictable over the past 2-3 years. Typically light menses,
not heavy. She states she has an OBGYN who she discussed these complaints with and told her it
was likely early menopause. She reports intermittent night sweats. She does report changes in
mood with intermittent crying and periods of sadness. She states her last Pap was 6 months ago,
had a mammogram the same day. She denies prior history of irregular Pap or mammogram.
States her OBGYN has ordered her mammograms in the past.
Musculoskeletal: States her entire body is sore, initially described as joint aches, adding that her
entire body is sore to touch, she points to her forearms and shoulders. Stating “just to touch me it
hurts.” The symptoms began over one year ago, possibly two years, she assumed she had the
start of arthritis and possibly menopause. She states the symptoms began to worsen
approximately 6 months ago around the time she started taking the blood pressure medicine. She
states the symptoms are worse in the morning, states she can hardly get out of bed upon waking
described as painful from the shoulders to heels, she feels “exhausted” although denies difficulty
sleeping. States the pain is bilateral, affecting all areas and repeatedly talks of pain in her
shoulders, forearms and entire lower legs. She denies stiff joints, no joint swelling or redness.
She denies prior evaluation by a rheumatologist. She states she has taken motrin and her
boyfriends ultram with minimal relief.
Skin: Denies rash, redness, excessive dry skin or suspicious lesions
Neurologic: Reports intermittent tingling to her fingertips, bilateral. Unable to pinpoint when this
was first noticed. Denies history of stroke or seizure, denies weakness or tremors. Denies
dizziness. Denies difficulty with memory, reports poor concentration.
Psychiatric: When asked if she feels depressed responds yes. She denies anxiety. In the past two
weeks she reports depressed mood, lack of interest in normal activities, difficulty sleeping,
fatigue and impaired concentration. States she feels overwhelmed from the daily pain, repeatedly
stating “I just don’t feel right.” She reports crying spells and sadness. States she feels tired all the
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time, does not want to wake in the morning, feels tired and has pain. Denies prior treatment for
depression. Denies thoughts of harming herself or others.
Endocrine: Denies history of DM or thyroid disease. Denies cold or heat intolerance, polydipsia,
polyphagia, polyuria
Heme/lymphatic: Denies history of anemia. Denies excessive bruising, denies enlarged lymph
nodes
Allergic/Immunologic: Denies urticaria, hay fever or persistent infections
Physical Examination
General: This is an obese African American female. Her height is 5 feet, 6 inches, weight
96.36kg, BMI 34.2. Her Vital signs include BP 148/98, HR 74, RR 20, T 36.6. She is in no
acute distress, alert and cooperative, making appropriate eye contact, oriented x4.
HEENT: Head is normocephalic. Eyes: Pupils are equal and reactive to light. Sclera and
conjunctiva are clear, white, without exudate Ears: Bilateral TMs are normal. The oropharynx
appears pink and moist, without erythema or exudate, tonsils of normal size. Dentition appears in
good condition. Gingiva appears healthy Neck: supple. Trachea midline. No lymphadenopathy
on palpation. No palpable thyroid enlargement, asymmetry, mass or nodules.
Heart: normal S1, S1, regular rhythm and rate, no murmur noted, no JVD, no carotid bruit
Lungs: Lungs are clear all lobes. No crackles or wheeze. Slightly diminished bases.
Abdomen: soft, obese, non-distended, non-tender, with active bowel sounds. No hepatomegaly
or splenomegaly on palpation
Extremities: no edema, palpable pulses
Musculoskeletal: Upper and lower extremity strength 5/5 equal bilaterally, full active ROM
present, no joint swelling or redness noted, no joint pain elicited with palpation. Light palpation
of the soft tissue elicits pain and guarding in the areas of the upper back, upper chest, shoulders,
upper and lower arms, hips and thighs.
Neurological: Cranial nerves 1-XII intact, Motor and sensory exam of the upper and lower
extremities is normal, DTRs graded 2+ bilaterally and symmetrical
Skin: No rash or redness, no swelling, dry in general
Assessment:
Myalgia (729.1)
-Start Amitriptyline 25mg po qHS
-CBC, CMP, TSH, CRP, ESR, RF, ANA
Depression (311)
-Start Prozac 20mg po once daily
-Counseling services offered. Refused at this time, states she will think about it
HTN (401.9)
-Start Lisinopril 10mg once daily.
-Advised home Bp monitoring 2-3 times weekly, record on a log and bring to next ov
-DASH diet
Tobacco Use Disorder (305.1)
Myalgia 19
-Advised cessation, discussed options to assist. Refusing, states is not emotionally ready
Appendix A
Obesity (278)
-Encouraged weight loss. DASH diet.
-Advised 30mins of exercise daily as recommended by the AHA
Follow up in 2 weeks.