Musculoskeletal pain

Template

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LateralityChoose oneFirst line

LocationChoose oneFirst line

Red flags presentChoose any

Red flags absentChoose any

ExamChoose one

AssessmentChoose one

ImagingChoose one

LabsChoose any

PlanChoose any

ReferralChoose one

DispositionChoose one

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Counseling paragraphChoose oneParagraph

CounselingNot in the note with these choices

Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Musculoskeletal pain
• No fever, night pain, weight loss, joint swelling, pinpoint bony tenderness, unexplained bruising, or limping
• Well appearing, with no swelling, full range of motion, and normal gait
• Pain most consistent with benign musculoskeletal pain without red flags on history or exam
• Supportive care with rest, ice or heat as helpful, gentle range of motion, and gradual return to activity as tolerated
• Follow up if worsening or not improving

Most aches and pains in active children come from muscles, minor injuries, or overuse and improve over days to a few weeks. Recommended supportive care with tylenol or motrin as needed and ice or heat, with an emphasis on gentle stretching and a gradual return to activity. Return precautions given including fever, swelling or redness of a joint, limping, night pain, pain that keeps getting worse, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Laterality, location
Red flags present or absent (fever, night pain, weight loss, joint swelling, bony tenderness, bruising)
Benign musculoskeletal pain, overuse, strain or bruise, needs evaluation
Imaging not indicated; x-ray; negative x-ray
Supportive care; tylenol or motrin
PT, orthopedics, rheumatology
Bone or joint infection

Return precautions in the template

feverswelling or redness of a jointlimpingnight painpain that keeps getting worse

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.