Assessing Muscoskeletal Pain

Patient Information:

XX, 15yo, Male

S.

CC: “Dull pain, both knees”

HPI:

• Location: Both knees (would ask him to point to the exact location)
• Onset: NA (would ask if onset was sudden or gradual, was he doing an activity when it occurred)
• Character: Dull, catching, clicking
• Associated signs and symptoms: NA (would ask if the pain wakes him up at night, what activities are limited due to the knee pain, can he straighten or bend the knees)
• Timing: NA (would ask when the pain occurs)
• Exacerbating/ relieving factors: NA (would ask what makes it worse, what makes it better)
• Severity: NA (would have pain rated on a scale of 0-10)
• Current Medications: NA (would ask what medication he is on if any)

Allergies: NA (would ask if any medication or food allergies)

PMHx: NA (would ask about general health, past illnesses,  past surgeries, hospitalizations, immunizations,  any blood transfusions, any psych history)

Soc Hx: NA (would ask if he works, and where, does he play sports and if so what and how often, does he smoke, does he drink alcohol, does he do any illicit drugs, does he drink caffeine, if so how much and how often for each, has he lost or gained any weight, does he follow a specific diet, and what about exercise) I would also ask if he uses sports safety equipment if he plays in sports, does he wear a seat belt, does he ride with others that may be impaired by drugs or alcohol.

Fam Hx: NA (would ask about parents, grandparents, sibling health history and any deaths, ask about cancer, cardiac diseases, diabetes)

ROS:

• GENERAL:  NA (would ask if any weight loss, fever, chills, weakness or fatigue)
• HEENT: NA Eyes, Ears, Nose, Throat (would ask if any drainage, problems, blurred vision, problems swallowing etc.)
• SKIN:  NA (would look for skin rashes, moles, or open wounds)
• CARDIOVASCULAR:  NA (would ask about heart problems, blood pressure, swelling to lower extremities)
• RESPIRATORY:  NA (would ask about shortness of breath, cough or sputum)
• GASTROINTESTINAL:  NA (would ask about anorexia, nausea, vomiting or diarrhea. abdominal pain or blood)
• GENITOURINARY:  NA (would ask about burning on urination, would address sexual activity/protection)
• NEUROLOGICAL:  NA (would ask about headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, changes in bowel or bladder control)
• MUSCULOSKELETAL:  unilateral to bilateral knee pain, clicking, and catching under the patella, (would further ask if he had any limping at time of knee pain, any back pain, joint pain or stiffness)
• HEMATOLOGIC:  NA (would ask if any anemia, bleeding or bruising)
• LYMPHATICS:  NA (would ask if patient noticed any enlarged nodes or has a history of splenectomy)
• PSYCHIATRIC:  NA (would ask if any history of depression or anxiety)
• ENDOCRINOLOGIC:  NA (would ask if any sweating, cold or heat intolerance, polyuria or polydipsia)
• ALLERGIES:  NA (would ask if history of asthma, hives, eczema or rhinitis)