Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Subjective:
Muscle weakness: Describe the current pattern and severity of muscle weakness, focusing on proximal (shoulders, hips) and/or distal (hands, feet) involvement as reported by the patient.
Functional limitations: Ask about how muscle weakness impacts daily activities (climbing stairs, dressing, ambulation).
Falls: Inquire about any recent falls and their relation to muscle weakness.
Pain: Assess the presence, location, and character of muscle pain or cramps.
Respiratory symptoms: Briefly inquire about any shortness of breath, particularly on exertion, which could indicate respiratory muscle involvement.
Family history: Ask about any family members with similar muscle weakness.
Objective:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure, oxygen saturation (if on oxygen).
Muscle strength testing: Document manual muscle testing (MMT) scores for major muscle groups in proximal and distal limbs.
Gait assessment: Briefly describe the patient’s gait pattern (waddling, difficulty initiating gait).
Range of motion testing: Assess passive range of motion in major joints, especially shoulders and hips, to identify contractures.
Reflexes: Test deep tendon reflexes (biceps, triceps, patellar, ankle) and document any abnormalities (hyporeflexia, absent reflexes).
Laboratory Results (if recent):
Mention relevant laboratory findings, including:
Creatine kinase (CK): Elevated levels may suggest muscle damage.
Genetic testing (if performed): Results can help confirm specific type of limb-girdle or distal dystrophy.
Imaging Studies (if recent):
Briefly describe findings from relevant imaging studies, such as:
MRI: Can reveal muscle atrophy, fatty replacement of muscle tissue.
Assessment:
Diagnosis: State the suspected or confirmed diagnosis of limb-girdle muscular dystrophy (LGMD) or distal dystrophy (DD) based on clinical features, family history, and potentially, genetic testing results.
Specific subtype (if known): If a specific type of LGMD or DD is identified, mention it here.
Disease severity: Briefly describe the perceived disease severity based on the extent of muscle weakness, functional limitations, and presence of complications.
Plan:
Treatment:
There is no cure for LGMD or DD, but treatment may include:
Physical therapy to maintain muscle strength and flexibility.
Occupational therapy to help with daily activities.
Assistive devices (canes, walkers) as needed.
Cardiac and respiratory monitoring for potential complications.
Mention any specific medications or therapies being considered or implemented (e.g., corticosteroids for some inflammatory subtypes).
Genetic counseling: Recommend genetic counseling for the patient and family members at risk.
Support groups: Inform the patient about available support groups for individuals with LGMD or DD.
Follow-up:
Schedule the next clinic visit for follow-up based on disease progression and the need for ongoing monitoring.
Instruct the patient to return sooner if they experience significant worsening of weakness, falls, or respiratory difficulties.