Diagnosis: Leg muscle pain, noninflammatory. Obesity.
Plan: I do not see any problems at this time with his laboratory or physical examination. His pain may be related to growing pains. The mother admitted that the primary care physician came to the same conclusion, but she wanted a second opinion. The mother also said then that she changed to new pillows and mattress a month ago, because her son grew considerably over the summer.
The pediatric rheumatologist recommends that the patient take 200 mg ibuprofen up to four times a day and use a heating pad on his leg muscles as needed, with caution to avoid burns. She encourages the boy to remain active. In her note to the primary care physician, she recommends counseling about weight loss and exercise.