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Assessment: The patient presents with joint pain and stiffness, particularly in weight-bearing joints (e.g., knees, hips), with symptoms worsening after activity and improving with rest. The differential diagnosis includes osteoarthritis, rheumatoid arthritis, gout, pseudogout, and tendinitis.
Plan: Educate the patient about osteoarthritis, emphasizing the importance of weight management and joint protection strategies. Recommend non-pharmacologic treatments such as physical therapy, low-impact exercise, and assistive devices as needed. For pharmacologic management, prescribe NSAIDs: ibuprofen 400-600 mg orally every 6-8 hours as needed (max 2400 mg/day) or naproxen 250-500 mg orally every 12 hours as needed (max 1000 mg/day), and consider acetaminophen as an alternative if NSAIDs are contraindicated. Schedule a follow-up in 6-8 weeks to reassess pain and function, and discuss further options like corticosteroid injections or topical analgesics if symptoms persist. Instruct the patient to report any new joint swelling, severe pain, or changes in function.
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