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1DVBCWFI3 ;ALB/RLC FIBROMYALGIA WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;Narrative: For VA compensation purposes, the diagnosis of fibromyalgia
7 ;;(sometimes called fibrositis, primary fibromyalgia syndrome, or
8 ;;myofascial pain syndrome) requires the presence of widespread
9 ;;musculoskeletal pain and tender points. Additional findings may also
10 ;;be present: fatigue, sleep disturbance, stiffness, paresthesias,
11 ;;headache, irritable bowel symptoms, depression, anxiety, or Raynaud's
12 ;;-like symptoms. Widespread pain is defined as pain in both the left
13 ;;and right sides of the body, that is both above and below the waist,
14 ;;and that affects both the axial skeleton (i.e., cervical spine,
15 ;;anterior chest, thoracic spine, or low back) and the extremities.
16 ;;Rule out other diagnostic entities that may be responsible for the
17 ;;symptomatology presented.
18 ;;
19 ;;A. Review of Medical Records:
20 ;;
21 ;;B. Medical History (Subjective Complaints):
22 ;;
23 ;; Comment on:
24 ;;
25 ;; 1. Date of onset of symptoms, date of diagnosis (if known).
26 ;; 2. Are symptoms constant or nearly so? If episodic, how often are they
27 ;; present? What precipitates and alleviates symptoms? Are they
28 ;; refractory to therapy?
29 ;; 3. Location, severity, frequency of any musculoskeletal pain,
30 ;; stiffness, or muscle weakness.
31 ;; 4. Unexplained fatigue, sleep disturbances, headaches, paresthesias.
32 ;; 5. GI symptoms.
33 ;; 6. Treatment, (type, duration, response, side effects). Has treatment
34 ;; been continuous?
35 ;; 7. Is there depression or anxiety?
36 ;; 8. Effects of symptoms on daily activities.
37 ;; 9. Lost time from work?
38 ;; 10. History of hospitalizations, dates and location, if known, reason.
39 ;;
40 ;;C. Physical Examination (Objective Findings):
41 ;;
42 ;; Address each of the following and fully describe current findings:
43 ;; (Please incorporate all ancillary study results into the final
44 ;; diagnosis.)
45 ;;
46 ;; 1. Musculoskeletal areas involved.
47 ;; 2. Trigger or tender points.
48 ;; 3. Muscle strength in involved areas.
49 ;;
50 ;;D. Diagnostic and Clinical Tests:
51 ;;
52 ;; 1. Include results of all diagnostic and clinical tests conducted
53 ;; in the examination report.
54 ;;
55 ;;E. Diagnosis:
56 ;;
57 ;; 1. Is the condition currently active or in remission?
58 ;;
59 ;;
60 ;;
61 ;;Signature: Date:
62 ;;END
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