Date:
Patient:
Admitting Diagnosis: Statin-induced myopathy
HPI (History of Present Illness):
Summarize the patient’s presentation, including:
Onset, duration, and location of muscle pain (often proximal, symmetrical)
Severity and character of pain (aching, cramping, weakness)
Any associated symptoms (e.g., fatigue, fever, rash)
Current statin use (dosage, type)
History of muscle pain with previous statin use
PMH (Past Medical History):
Relevant medical history including:
Underlying medical conditions requiring statin therapy (e.g., hyperlipidemia, coronary artery disease)
Comorbidities that may increase risk of myopathy (e.g., renal dysfunction, hypothyroidism, uncontrolled diabetes)
History of muscle disease or injury
Concomitant medications that may interact with statins (e.g., cyclosporine, gemfibrozil)
Physical Exam:
Vital signs (including temperature)
Musculoskeletal exam:
Muscle tenderness (especially proximal muscle groups)
Muscle weakness
Labs:
Creatine kinase (CK) level (elevated levels suggestive of myopathy)
Thyroid function tests (TSH)
Basic metabolic panel (electrolytes, renal function)
Imaging:
Electromyography (EMG) / Muscle biopsy (may be obtained in some cases to confirm myopathy)
Diagnosis:
Statin-induced myopathy
Plan:
Discontinuation of the statin:
Consider alternative lipid-lowering therapy (e.g., ezetimibe, PCSK9 inhibitors)
Pain management (e.g., NSAIDs, muscle relaxants)
Monitoring of CK levels
Progress Notes:
Document daily progress including:
Response to statin discontinuation (improvement in pain, CK levels)
Effectiveness of pain management strategies
Consideration of restarting statin therapy at a lower dose or with alternative statin type (if necessary)
Discharge Planning:
Education on statin-induced myopathy and importance of medication adherence
Follow-up plan with physician to monitor CK levels and adjust medications as needed
Discussion of alternative lipid-lowering strategies if statin rechallenge is not possible
Note: This is a template and should be adapted to the specific patient’s presentation, test results, and course of treatment.