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Routine: DVBCWFI5

DVBCWFI5.m

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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