Subjective
Date of visit
Reason for visit (initial evaluation for suspected polymyalgia rheumatica (PMR), follow-up for diagnosed PMR)
History of present illness:
Symptoms (usually begin abruptly and are symmetrical):
Proximal muscle stiffness and pain (shoulders, hips, buttocks) – worse in the morning and after inactivity
Morning stiffness lasting at least 1 hour
Difficulty with daily activities (dressing, getting out of bed)
Low-grade fever (may be present)
Fatigue
Weight loss (unintentional)
Duration of symptoms
Past medical history (relevant conditions, previous treatments for PMR)
Giant cell arteritis (GCA) history (important as PMR and GCA can coexist)
Medications (current medications, including corticosteroids)
Allergies
Objective
Vital signs (temperature, heart scalp tenderness) – may be elevated temperature with active disease
Physical exam:
General (assessing for signs of systemic inflammation)
Musculoskeletal exam:
Tenderness to palpation in proximal muscle groups (shoulders, hips)
Limited range of motion in affected joints
Temporal artery examination (palpating for tenderness or nodules) – may suggest GCA
Assessment
Suspected polymyalgia rheumatica based on clinical presentation (inflammatory symptoms and morning stiffness)
Consideration of alternative diagnoses (other inflammatory myopathies, osteoarthritis)
Giant cell arteritis (consideration based on symptoms and physical exam)
Plan
Diagnostic workup (may include some of the following):
Laboratory tests:
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – elevated levels are suggestive of PMR (not specific)
Rheumatoid factor and anti-CCP antibody testing (to rule out rheumatoid arthritis)
Imaging studies (not routinely done for PMR but may be considered to rule out other diagnoses)
Treatment (initiated based on high suspicion for PMR):
Corticosteroids (prednisone) – the mainstay of treatment for PMR
Slow tapering of corticosteroids as symptoms improve
Calcium and vitamin D supplementation (to prevent osteoporosis – a side effect of long-term corticosteroid use)
Education
Explain polymyalgia rheumatica, its symptoms, and the importance of early diagnosis and treatment.
Discuss the planned treatment with corticosteroids and potential side effects.
Importance of adhering to medication schedule and following up for monitoring.
Warning signs and symptoms of giant cell arteritis (headache, jaw claudication) to report promptly.
Follow-up
Schedule for close follow-up appointments initially (weeks to months)
Monitor response to treatment (symptom improvement, ESR/CRP levels)
Adjust corticosteroid dose as needed
Monitor for potential side effects of corticosteroids
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of polymyalgia rheumatica.