Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Progression of muscle weakness:
Ask about difficulty with tasks like climbing stairs, standing from a seated position, running.
Inquire about the use of assistive devices (cane, wheelchair).
Contractures and joint pain:
Document any limitations in joint mobility (elbows, hips, knees, ankles).
Assess for pain associated with contractures.
Respiratory function:
Inquire about shortness of breath, particularly with exertion.
Ask about nighttime cough or difficulty sleeping due to respiratory issues.
Cardiac function:
Document any history of heart problems or symptoms like chest pain, palpitations.
Psychosocial concerns:
Explore emotional well-being and coping with the challenges of DMD.
Inquire about social interaction and participation in activities.
Objective:
Vital Signs: Include heart rate, blood pressure, respiratory rate, oxygen saturation (SpO2).
Physical Exam:
Muscle strength: Manual muscle testing to assess upper and lower extremity strength.
Gait and balance: Evaluate walking pattern, need for assistance, and risk of falls.
Joint mobility: Assess range of motion in elbows, hips, knees, and ankles for contractures.
Cardiac exam: Listen for heart murmurs or abnormal heart sounds.
Respiratory exam: Check for signs of respiratory distress (accessory muscle use, chest retractions).
Assessment:
Duchenne muscular dystrophy (DMD) confirmed by genetic testing (if available) or based on clinical presentation and elevated creatine kinase levels.
Functional status: Specify the current ambulation status (independent, cane use, wheelchair dependence).
Contractures (if present): Indicate location and severity of joint limitations.
Respiratory function: Document any concerns about respiratory compromise.
Cardiac status: Mention any identified cardiac complications.
Psychosocial considerations: Address emotional well-being and social participation.
Plan:
Physical Therapy:
Maintain and improve muscle strength and range of motion through stretching and strengthening exercises.
Address contractures with splinting or physical therapy interventions.
Respiratory Therapy:
Evaluate need for nighttime respiratory support (e.g., BiPAP) if respiratory function declines.
Respiratory hygiene education to manage secretions.
Cardiac Monitoring:
Schedule regular checkups with a cardiologist to monitor heart function, especially if there are concerning symptoms.
Corticosteroids:
Discuss the use of corticosteroids (prednisone) to prolong ambulation and muscle strength, considering potential side effects.
Other medications:
Mention other medications used for symptom management, such as pain relievers.
Supportive Care:
Nutritional counseling to ensure adequate caloric intake and maintain muscle health.
Occupational therapy to assist with activities of daily living (ADLs).
Genetic counseling for the patient and family.
Follow-up:
Schedule regular clinic visits to monitor disease progression, functional abilities, and response to treatment.
Consider referral to specialists (pulmonologist, cardiologist) for ongoing management.
Discuss participation in clinical trials for promising DMD therapies (if applicable).
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant findings regarding muscle weakness, contractures, respiratory function, cardiac status, and treatment plan. Include considerations for psychosocial support and adjunctive therapies.