VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWFI3.m

63 lines
2.4 KiB
Mathematica

DVBCWFI3 ;ALB/RLC FIBROMYALGIA WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
;
;
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 of onset of symptoms, date of diagnosis (if known).
;; 2. Are symptoms constant or nearly so? If episodic, how often are they
;; present? What precipitates and alleviates symptoms? Are they
;; refractory to therapy?
;; 3. Location, severity, frequency of any musculoskeletal pain,
;; stiffness, or muscle weakness.
;; 4. Unexplained fatigue, sleep disturbances, headaches, paresthesias.
;; 5. GI symptoms.
;; 6. Treatment, (type, duration, response, side effects). Has treatment
;; been continuous?
;; 7. Is there depression or anxiety?
;; 8. Effects of symptoms on daily activities.
;; 9. Lost time from work?
;; 10. History of hospitalizations, dates and location, if known, reason.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; (Please incorporate all ancillary study results into the final
;; diagnosis.)
;;
;; 1. Musculoskeletal areas involved.
;; 2. Trigger or tender points.
;; 3. Muscle strength in involved areas.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. Is the condition currently active or in remission?
;;
;;
;;
;;Signature: Date:
;;END