Symptom: Pain, Muscle

Initial Grading Reminder

Grade 1: Mild pain
Grade 2: Moderate pain; limiting instrumental ADLs
Grade 3: Severe pain; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you done any activity recently that could have contributed to the muscle pain? When did the symptom start? Has it developed gradually or suddenly? Have you had any muscle pain in the past?

Grade the symptom

Ask the patient:

How would you rate your muscle pain: is it mild, moderate, or severe? Is it limiting your ability to do the things you want to do or take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you feeling foggy or confused? Have you been vomiting? Is your urine tea-colored?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with new-onset moderate or worse (or worsening) muscle pain should be evaluated.

    Patients with any of the red-flag symptoms should be evaluated immediately.

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    Nursing Assessment of Potential Causes

    Nephritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient look ill?
    • Has there been change in urination?
      • Urine color?
      • Frequency?
    • How much fluid is the patient taking in?
    • Are associated symptoms present?
      • Nausea?
      • Headache?
      • Malaise?
      • Lung edema?
    • Are there symptoms indicative of:
      • Urinary tract infection?
      • Pyelonephritis?
      • Worsening CHF?
    • Are symptoms limiting ADLs?
    • Current or recent use of nephrotoxic medications (prescribed and OTC), other agents?
      • NSAIDs
      • Antibiotics
      • Contrast media or other nephrotoxic agents (contrast dye, aminoglycosides, PPI)?
    • Laboratory abnormalities (elevated creatinine, electrolyte abnormalities)
    • Urinalysis abnormalities (casts)
    • Abdominal or pelvic disease that could be causing symptoms
    • Prior history of renal compromise?
    • Other immune-related adverse effects?
    • Presence of current or prior immune-mediated toxicities, including rhabdomyolysis
    • Is patient volume depleted?

    Arthralgias and Arthritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is gait affected?
    • Obvious swollen or deformed joint(s)?
    • Is the patient having trouble getting up and down stairs?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Are symptoms increasing the patient’s risk for fall? Other safety issues?
    • Associated symptoms?
      • Fatigue (new or worsening)
    • Is there a pre-existing autoimmune dysfunction?
    • Is there a history of prior orthopedic injury, DJD, OA, RA?
    • Other immune-related adverse effects
    • Three subtypes of inflammatory arthritis associated with checkpoint inhibitors:
      1. Polyarthritis similar to rheumatoid arthritis
      2. True reactive arthritis with conjunctivitis, urethritis, and oligoarthritis
      3. Subtype similar to seronegative spondyloarthritis with inflammatory back pain and predominantly larger joint involvement


    Pain, muscle weakeness, vomiting, confusion, tea-colored urine, laboratory markers (elevated creatine kinase levels)

    Differential Diagnosis

    What do you suspect is the cause of the muscle pain?