Fibromyalgia
HISTORY:
for
Onset: , following
Location: ,
Severity: , / 10
Impact on daily activities:
Type:
Pattern: , worse during the
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , ,
- Sleep study
-
-
-
-
-
- Regular exercise
- Stress management techniques
- Sleep hygiene
- Cognitive behavioral therapy
- Physical therapy
- Advise that treatment goals are to improve symptoms and quality of life
- Referral to rheumatologist
- Referral to psychologist
- Follow-up in
- Return if symptoms worsen, if new symptoms develop such as joint swelling or redness, or if symptoms do not improve with treatment