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Routine: DVBCWFI1

DVBCWFI1.m

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  1. DVBCWFI1 ;ALB/CMM FIBROMYALGIA WKS TEXT - 1 ; 6 MARCH 1997
  1. ;;2.7;AMIE;**12**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;Narrative: For VA compensation purposes, the diagnosis of fibromyalgia
  1. ;;(sometimes called fibrositis, primary fibromyalgia syndrome, or
  1. ;;myofascial pain syndrome) requires the presence of widespread
  1. ;;musculoskeletal pain and tender points. Additional findings may also
  1. ;;be present: fatigue, sleep disturbance, stiffness, paresthesias,
  1. ;;headache, irritable bowel symptoms, depression, anxiety, or Raynaud's
  1. ;;-like symptoms. Widespread pain is defined as pain in both the left
  1. ;;and right sides of the body, that is both above and below the waist,
  1. ;;and that affects both the axial skeleton (i.e., cervical spine,
  1. ;;anterior chest, thoracic spine, or low back) and the extremities.
  1. ;;Rule out other diagnostic entities that may be responsible for the
  1. ;;symptomatology presented.
  1. ;;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;;
  1. ;; Comment on:
  1. ;; 1. Date of onset of symptoms, date of diagnosis (if known).
  1. ;;
  1. ;;
  1. ;; 2. What precipitates and alleviates symptoms?
  1. ;;
  1. ;;
  1. ;; 3. Location, severity, frequency of any musculoskeletal pain,
  1. ;; stiffness, or muscle weakness, whether episodic or constant,
  1. ;; and what their effects are on daily activities.
  1. ;;
  1. ;;
  1. ;; 4. Unexplained fatigue, sleep disturbances.
  1. ;;
  1. ;;
  1. ;; 5. GI symptoms.
  1. ;;
  1. ;;
  1. ;; 6. Treatment, (type, duration, response). Has treatment been
  1. ;; continuous?
  1. ;;
  1. ;;
  1. ;; 7. Is there depression or anxiety?
  1. ;;
  1. ;;
  1. ;; 8. Lost time from work?
  1. ;;
  1. ;;
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Address each of the following and fully describe current findings:
  1. ;; (Please incorporate all ancillary study results into the final
  1. ;; diagnosis.)
  1. ;;
  1. ;; 1. Is the condition currently active or in remission?
  1. ;;
  1. ;;
  1. ;; 2. Musculoskeletal areas involved.
  1. ;;
  1. ;;
  1. ;; 3. Trigger or tender points.
  1. ;;
  1. ;;
  1. ;; 4. Muscle strength in involved areas.
  1. ;;
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;;
  1. ;;
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END