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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 Myalgia 2 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. Myalgia 3 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 Myalgia 4 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 Myalgia 5 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). Myalgia 6 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). Myalgia 7 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 Myalgia 8 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 Myalgia 9 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 Myalgia 10 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. Myalgia 11 -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 Myalgia 12 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. Myalgia 13 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. Myalgia 14 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 Myalgia 15 References http://www.rheumatology.org/practice/clinical/classification/fibromyalgia/1990_Criteria_ for_Classification_Fibro Myalgia 16 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 Myalgia 17 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 Myalgia 18 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.