What is the appropriate note template for an 88-year-old woman with a muscle strain around the lower part of her right (R) rib cage?

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From the Guidelines

For an 88-year-old woman with muscle strain around the lower right rib cage, I recommend a conservative treatment approach, prioritizing pain management and mobility to minimize morbidity and mortality, and improve quality of life. The patient should start with acetaminophen (Tylenol) 500-650mg every 6 hours as needed for pain, not exceeding 3000mg daily due to age-related concerns, as recommended by the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1. Applying a heating pad to the affected area for 15-20 minutes several times daily can improve blood flow and reduce muscle tension. Gentle stretching exercises, focusing on slow, controlled movements without pain, can help maintain mobility.

Key Considerations

  • Rest is important but complete immobilization should be avoided as it may lead to muscle weakness and stiffness.
  • The patient should avoid activities that exacerbate pain for 1-2 weeks.
  • If pain persists beyond 2-3 weeks or worsens significantly, further evaluation is warranted to rule out rib fracture or other conditions.

Pain Management

  • Acetaminophen is the first-line treatment for managing acute trauma pain in the elderly, according to the 2023 WSES guidelines 1.
  • NSAIDs should be avoided due to increased risk of gastrointestinal bleeding and kidney issues in elderly patients.
  • The implementation of a Multi-Modal-Analgesia approach, including acetaminophen, gabapentinoids, and lidocaine patches, can be considered for elderly patients with severe pain, as recommended by the 2023 WSES guidelines 1.

Additional Recommendations

  • The patient's vital signs and clinical features should be closely monitored to define the risk of end-of-life care, as recommended by the 2023 WSES guidelines 1.
  • Involving the palliative care team as soon as possible can be beneficial in managing elderly severely injured patients at the end-of-life status, as recommended by the 2023 WSES guidelines 1.

From the Research

Note Template for an 88-year-old Woman with a Muscle Strain

Patient Information

  • Age: 88 years old
  • Sex: Female
  • Chief Complaint: Muscle strain around the lower part of her right (R) rib cage

History of Present Illness

  • The patient presents with acute pain in the lower part of her right rib cage
  • The pain may have occurred during strenuous activity 2, 3
  • The patient's history should be taken to determine the cause of the muscle strain and to rule out other possible causes of pain

Physical Examination

  • The physical examination should include an assessment of the patient's muscle strength, flexibility, and range of motion
  • The examination should also include a check for any signs of injury, such as bruising or swelling

Diagnosis

  • The diagnosis of a muscle strain can usually be made based on the patient's history and physical examination 2
  • Imaging studies, such as magnetic resonance imaging (MRI), may be recommended if the diagnosis is unclear or if the patient has a history of previous injuries 2, 3

Treatment

  • The initial treatment for a muscle strain should include rest, ice, compression, and nonsteroidal anti-inflammatory drug therapy 2
  • As the pain and swelling subside, physical therapy should be initiated to restore flexibility and strength 2
  • The patient should be advised to avoid excessive fatigue and to perform adequate warm-up before intense exercise to prevent further injury 2, 3

Medication Management

  • The patient may be prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol to manage pain and inflammation 4
  • The patient should be advised of the potential risks and benefits of these medications and should be monitored for any adverse effects

Follow-up Care

  • The patient should be followed up regularly to monitor her progress and to adjust her treatment plan as needed
  • The patient should be advised to return to the clinic if she experiences any increase in pain or if she has any concerns about her condition.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Muscle strain injury: diagnosis and treatment.

The Journal of the American Academy of Orthopaedic Surgeons, 1999

Research

Muscle strain injuries.

The American journal of sports medicine, 1996

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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