©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWFI5 ;ALB/RLC FIBROMYALGIA WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
;
;
TXT ;
;;Narrative: For VA compensation purposes, the diagnosis of fibromyalgia
;;(sometimes called fibrositis, primary fibromyalgia syndrome, or
;;myofascial pain syndrome) requires the presence of widespread
;;musculoskeletal pain and tender points. Additional findings may also
;;be present: fatigue, sleep disturbance, stiffness, paresthesias,
;;headache, irritable bowel symptoms, depression, anxiety, or Raynaud's
;;-like symptoms. Widespread pain is defined as pain in both the left
;;and right sides of the body, that is both above and below the waist,
;;and that affects both the axial skeleton (i.e., cervical spine,
;;anterior chest, thoracic spine, or low back) and the extremities.
;;Rule out other diagnostic entities that may be responsible for the
;;symptomatology presented.
;;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Date and circumstances of onset.
;; 2. History of hospitalizations or surgery, dates and locations, if known,
;; and reason.
;; 3. Report which of the following are present: Unexplained fatigue, sleep
;; disturbances, headaches, paresthesias, diarrhea, constipation,
;; alternating constipation and diarrhea, abdominal cramps or bloating,
;; depression, anxiety, Raynaud's-like symptoms, musculoskeletal symptoms.
;; 4. For musculoskeletal symptoms, describe type (myalgia, arthralgia,
;; stiffness, etc.) and location. State whether pain, if present, is
;; widespread (meaning in both the left and right sides of the body, both
;; above and below the waist, and that affects both the axial skeleton
;; (i.e., cervical spine, anterior chest, thoracic spine, or low back)
;; and the extremities).
;; 5. State whether symptoms are constant, or nearly so, or are episodic.
;; If episodic, are they present more than one-third of the time?
;; 6. What precipitates or exacerbates symptoms?
;; 7. Treatment, (type, duration, response, side effects). Is continuous
;; medication required for control? Are symptoms refractory to therapy?
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;;
;; 1. Vital signs.
;; 2. Indicate all tender points found (and state if on left, right, or both
;; sides) from the following list of fibromyalgia tender points
;; identified by the American College of Rheumatology.
;; Occiput: at the suboccipital muscle insertions.
;; Low cervical: at the anterior aspects of the intertransverse spaces
;; at C5-C7.
;; Trapezius: at the midpoint of the upper border.
;; Supraspinatus: at origins, above the scapula spine near the medial
;; border.
;; Second rib: at the second costochondral junctions, just lateral to
;; the junctions on upper surfaces.
;; Lateral epicondyle: 2 cm distal to the epicondyles.
;; Gluteal: in upper outer quadrants of buttocks in anterior fold of
;; muscle.
;; Greater trochanter: posterior to the trochanteric prominence.
;; Knee: at the medial fat pad proximal to the joint line.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. As appropriate, to rule out other conditions.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. Diagnosis and date of diagnosis, if known.
;; 2. Is the condition currently active or in remission?
;; 3. State amount of time lost from work during past 12-month period due to
;; fibromyalgia.
;; 4. Describe the effects of the condition on usual occupation and daily
;; activities.
;;
;;
;;
;;Signature: Date:
;;END