Date:
Patient:
MRN:
Clinician: (Rheumatologist, Pain Specialist)
Reason for Visit:
Follow-up for fibromyalgia
Evaluation of symptom severity and impact on function
Medication adjustment or response assessment
Discussion of non-pharmacological management strategies
History of Present Illness:
Briefly describe the patient’s current status:
Duration of fibromyalgia symptoms (widespread pain, fatigue, sleep disturbances, cognitive issues)
Current pain intensity and location
Impact of symptoms on daily activities (work, sleep, social life)
Response to current medications and any side effects
Past Medical History:
Include any relevant past medical conditions (depression, anxiety, irritable bowel syndrome) that may coexist with FM.
History of injuries or surgeries
Family History:
Presence of fibromyalgia or other chronic pain conditions in first-degree relatives
Social History:
Stress levels and coping mechanisms
Sleep habits (quality and duration)
Physical activity level
Physical Exam:
General: Overall health and well-being
Musculoskeletal: Tenderness to palpation at specific trigger points
Assessment Tools:
Consider mentioning the use of validated FM assessment tools (e.g., Fibromyalgia Impact Questionnaire (FIQ), Fibromyalgia Severity Scale (FIQ-S)) to quantify symptom severity and impact on function.
Labs (limited role in diagnosis):
While labs are not diagnostic for FM, consider mentioning specific labs ordered to rule out other conditions:
Complete blood count (CBC) and erythrocyte sedimentation rate (ESR) – to rule out inflammatory conditions.
Thyroid function tests – to assess for thyroid disorders that can mimic FM symptoms.
Imaging (not routinely used for diagnosis):
Imaging studies are not necessary for FM diagnosis but may be performed to rule out other conditions causing pain.
Assessment:
Confirm the diagnosis of fibromyalgia based on clinical criteria (widespread pain, multiple tender points) and symptom duration.
Assess the severity of fibromyalgia and its impact on the patient’s life.
Evaluate for potential contributors to pain and fatigue (stress, sleep problems, comorbidities).
Plan:
Outline a comprehensive treatment plan considering both pharmacological and non-pharmacological approaches:
Medications: Low-dose antidepressants (amitriptyline, duloxetine) for pain and sleep, potentially muscle relaxants for muscle tension.
Non-pharmacological therapies:
Exercise therapy (aerobic and strength training) to improve pain, function, and mood.
Cognitive behavioral therapy (CBT) to manage stress and improve coping skills.
Patient education about FM and self-management strategies (sleep hygiene, relaxation techniques).
Physical therapy for pain management and improving flexibility.
Prognosis:
Briefly discuss the prognosis. Fibromyalgia is a chronic condition, but management strategies can significantly improve symptoms and quality of life.
Education:
Document any education provided to the patient regarding:
The nature of fibromyalgia and its symptoms
The importance of self-care and healthy lifestyle habits (sleep, exercise, stress management)
The benefits and potential side effects of medications
The availability of support groups and resources for fibromyalgia patients
Notes:
Include any additional relevant information not covered above, such as the patient’s emotional well-being, adherence to recommendations, and any specific concerns they may have.
Consider mentioning the importance of ongoing communication and potential need to adjust the treatment plan over time.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.