Generalized pain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍widespread musculoskeletal painunexplained pain

Onset was ‍gradualsudden, and occurred ‍whileafter ‍

Location is ‍widespread, ‍migrating

Rated at ‍012345678910 / 10 ‍

Impact on daily activities: ‍minimalmoderateseveredebilitating

Described as ‍deep acheburningthrobbing

Pattern ‍persistentintermittent

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍fatigue

‍sleep disturbances

‍headaches

‍depression

‍anxiety

‍memory loss

‍difficulty concentrating

‍numbness or tingling in the hands and feet

‍sensitivity to cold



Contributing factors:

‍stressful events

‍past emotional trauma

no history of: ‍osteoarthritis, ‍autoimmune diseases, ‍hypothyroidism, ‍chronic headache, ‍irritable bowel syndrome, ‍chronic fatigue syndrome, ‍depression

no use of: ‍new medications

no family history of: ‍fibromyalgia





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Fibromyalgia ‍likelysuspectedpossible

DDx: fibromyalgia, chronic fatigue syndrome, hypothyroidism, osteoarthritis, rheumatoid arthritis, lupus, polymyalgia rheumatica, myofascial pain syndrome, multiple sclerosis, depression, anxiety, somatoform disorders, statin-related myalgias, medication side effect, sleep apnea, vitamin D deficiency, electrolyte imbalance, neuromuscular disorders





PLAN:

Investigations:

- Blood work: ‍CBC, ‍creatinine, ‍electrolytes, ‍LFTs, ‍CRP, ‍ESR, ‍TSH, ‍vitamin D, ‍vitamin B12, ‍calcium, ‍magnesium, ‍phosphate, ‍albumin

- Sleep study

Treatments:

- ‍Analgesics

- ‍NSAIDs

- ‍Antidepressants

- ‍Anticonvulsants

- ‍Muscle relaxants

- Regular exercise

- Stress management techniques

- Sleep hygiene

- Cognitive behavioral therapy

- Physical therapy

- Advise that treatment goals are to improve symptoms and quality of life

Further care:

- Referral to rheumatologist

- Referral to psychologist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen, if new symptoms develop such as joint swelling or redness, or if symptoms do not improve with treatment