SOAP Note: Fibromyalgia

SOAP Note: Fibromyalgia

Instructions

 

This is a comprehensive SOAP note on a female 30-year-old newly diagnosed with fibromyalgia.

Primary diagnosis: Fibromyalgia

Differential diagnosis: Hypothyroidism, Bursitis, Anxiety

References no more than 3 years old.

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THE HISTORY AND PHYSICAL (H&P)

 

Solution

 

SOAP Note: Fibromyalgia

 

Patient’s Details

Initials: M.L.               Age: 30 years                      Race: White                      Gender: Female

SUBJECTIVE:

Chief Complaint (CC): “I have been experiencing dull and constant pain all over my body. The pain occurs with extreme fatigue and stiffness in the joints especially in the morning. These symptoms have significantly affected my ability to function. I am psychologically troubled by these symptoms and I just need your help.”

History of Present Illness (HPI): M.L., a 30-year-old white female, has reported to the clinic complaining of dull and constant pain all over her body. M.L. reports that the pain occurs with extreme fatigue and stiffness in the joints especially in the morning. These symptoms have significantly affected her general ability to function. She is psychologically troubled by these symptoms and just needs help from a healthcare professional.

These symptoms have persisted for the past three months. M.L. does not associate her symptoms to a recent traumatic event. As reported by M.L., several other symptoms occur together with the ones already described and they include; memory difficulties, affected abilities to concentrate and think, frequent pain around the head and jaws, abdominal pain, boating, sleep disturbance, and a burning or pricking sensation in the hands and feet.

One thing that worries M.L. the most is that the pain and fatigue symptoms do not subside even with common painkillers and enough sleep. M.L. indicates that nothing relieves the pain but it is always constant. She denies having any other medical conditions. She reports using 2 tablets of Tylenol every six hours daily. The pain goes away only for a short period of time after using the medication but returns with high severity. She describes the pain level as 9/10 on the pain scale.

III. Past medical history (PHx)

  1. Childhood illnesses

Denies known childhood illnesses

  1. Immunizations

As per her medical records, M.L. was immunized according to the schedule provided by the Centers for Disease Control. She received hepatitis B vaccine; 1st and 2nd doses, polio vaccine, rotavirus vaccine; 1st and 2nd doses, varicella vaccine, measles, mumps, rubella (MMR) vaccine, hepatitis A vaccine, pneumonia vaccine, and diphtheria, pertussis, and tetanus (DPT) vaccine. Her last influenza vaccine was on 05/01/2022.

  1. Adult Illnesses

M.L. reports malaria diagnosis at the age of 25 years. She was not hospitalized but was able to recover after treatment.

  1. Operations

Denies a history of surgery.

  1. Allergies

No known drug or food allergies reported.

  1. Medications

M.L. is currently using Tylenol to manage her pain. However, the drug does not improve her symptoms

  1. Complimentary treatments

She reports using massage of the joints to improve stiffness, especially in the morning.

  1. Family history

M.L. is her parents’ only daughter. Both father and mother are alive. Her father is 61 years old and her mother is 57 years. Parents have not been diagnosed by any medical condition. Maternal and paternal grandparents are all alive. She is not aware whether they have any medical conditions.

  1. Social history

M.L. is unemployed and reports that she spends better part of the day at home with the kids. Part of her daily activities include performing domestic chores and taking care of the children. She is married and they have been blessed with three children: 2 boys and a daughter. Her husband is a mechanic at a nearby tea factory. M.L. denies consuming cigarettes, alcohol, or illicit substances like heroin and cocaine.

She states that the family diet comprises of directly cooked foods and denies consuming processed foods. M.L. denies doing exercise or being part of a community exercise program. According to M.L., her husband is the sole bread winner of the family. They spend the little income he is getting from his job to acquire basic needs and pay medical bills. She is sexually active and reports being faithful to her husband.

  1. Review of Systems

General: Reports significant weight loss in the recent months. Reports extreme fatigue, severe and widespread pain, discomfort, psychological distress, memory impairment, head pain, and digestive issues. M.L. has not had a physical exam since she fell ill at the age of 25 years.

Skin: Denies skin itchiness/pruritus, rashes, or lesions. Denies redness, bruises, or petechiae. Does not report recent changes in hair or nail color.

HEENT:

Head: Denies recent trauma of the head. Reports a headache. Reports frequent head pain.

Eyes: Denies watery eyes. Denies excessive tearing or redness. Report mild eye pain. Reports dry eyes. Reports eye irritation and foreign body sensation. Denies pressure around the eyes. Reports blurred vision. Denies a history of cataracts or glaucoma. M.L. does not use contact glasses. She has not had an eye exam lately.

Ears: Reports mild pain around the ears. Denies hearing loss, ringing in the ears, or ear infections. Denies fullness in the ears. Denies a history of vertigo, tinnitus, or earache.

Nose and sinuses: Denies nasal congestion or runny nose. Reports sinus pain and the facial region. Denies a history of nasal polyps. Denies altered smelling abilities. Does not report sneezing or nasal itching.

Mouth and throat: Denies mouth sores, lesions, or ulcers. Denies sore throat. Denies a cough. Denies mouth dryness. Reports mild aching of the jaws. Denies pyorrhea. Does not report a history of strep throats or bleeding gums or dental carries.

Neck: Reports pain in the neck region, especially when she tries to turn her head. Denies the presence of lumps in the neck region. Denies swollen lymph nodes. Denies a history of goiter.

Lymphatics: Does not report a history of swollen axillae or lymph nodes in the inguinal and epitrochlear areas.

Breasts: Does not report discomfort, pain, lumps, or discharge from both breasts.

Pulmonary: Reports breathing problems characterized by pain around the chest as the lungs contract and relax. Denies a cough. Reports extreme fatigue. Does not report hemoptysis. Denies pleuritic chest pain, wheezing, cyanosis, recurrent pneumonia, or a history of tuberculosis. Denies a history of asthma.

Cardiovascular: Denies shortness of breath. Denies dyspnea palpitations, edema, or a history of cardiovascular problems. Denies chest pain, irregular heartbeat, or heart murmurs. Does not report a history of high blood pressure, myocardial infarction, or rheumatic fever reported.

Gastrointestinal: Reports constipation, abdominal pain, bloating, and excessive belching. Reports indigestion. Reports nausea. Reports increased bowel movements characterized by loose stool. Denies vomiting. Denies a history of jaundice or gallbladder problems. Reports reduced appetite. Denies rectal bleeding.

Urinary: Reports pain in the lower abdomen. Denies dysuria or pain in the genitals during urination. Denies a reduction in urine volume. Denies hematuria or the presence of blood in urinary. Denies a history of urinary tract infections.

Genital tract (female): Age of menarche was at 13 years. Last menstrual period was 5 days ago. The number of days per cycles is 28 days with menses taking 3-4 days. Denies postcoital bleeding, pain during intercourse/dyspareunia, or vaginal pruritus. Reports condom use as a contraceptive measure. Denies a history of sexually-transmitted diseases (STDs). Denies having a Pap smear before. Denies sexual difficulty or pregnancy-related complications. Denies vaginal discharge.

Musculoskeletal: M.L. reports pain in almost all joints of the body. Reports joint stiffness especially in the morning. Reports joint tenderness and backache. Reports widespread musculoskeletal pain. Reports severe limitations of motion. Denies a history of gout, arthritis, or a history of fractures.

Neurologic: Reports seizures and blackout. Reports extreme fatigue. Reports paresthesia characterized by a prickling or burning sensation in the hands, legs, arms, and feet. Reports memory impairment. Reports headache. Reports dizziness. Reports frequent back pain and around the head. Reports numbness. Reports muscle tension.

Psychiatric: Reports depression, anxiety, and sleep disturbance/insomnia. Reports memory impairment and inability to think properly. Denies irritability, nervousness, or nightmares. Does not report suicidal ideation. Denies a history of serious mental illnesses. Reports hypersomnia.

Endocrine: Denies heat or cold intolerance. Denies excessive thirst, abnormal night sweats, or excessive hunger. No thyroid issues reported. Denies excessive urination. Denies a history of diabetes.

Hematologic: Denies easy bruising, anemia, or abnormal bleeding. Denies a history of blood transfusion or reactions.

VII. Physical examination

Vital signs: Temperature; 35.8degree Celsius, Blood pressure; 126/73, respiratory rate; 19 breaths per minute, pulse; 91 beats per minute, weight; 147.6 lbs.

General appearance: M.L. looks fatigued, depressed, and confused. She is well-groomed and neatly dressed. She is appropriately oriented to time, place, and person

Skin: Skin is warm, intact, and without rashes. No evidence of cyanosis on the nail beds. Nails are without ridges.

HEENT:

Head: Lacks evidence of trauma. Head is normocephalic. No signs of alopecia.

Eyes: No evidence of lesions or swelling of the eyelids. PERRLA. Pink conjunctivae. No signs of hemorrhage of conjunctivae or icterus.

Ears: No tenderness or edema. No evidence of discharge or blockage in the ear canal. The tympanic membrane is pale grey in color.
Nose: Nasal mucosa pink, moist, and hairy. Midline septum is at the midline position. No evidence of drainage or blockage.

Mouth/Throat: Oral mucosa is moist and pink with good dentition on the gums. Pain on the sides of the jaws on palpation.

Neck: Trachea is positioned midline. Evidence of pain in the neck region and shoulder on palpation.

Nodes: The inguinal, axillary, and epitrochlear nodes do not have signs of swelling.

Chest: No crackles, wheezes, rhonchi, or rubs. Normal breath sounds noticed.

Heart: Regular heart rate or rhythm. No noise on a bilateral basis. Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. Midclavicular PMI visible, 5th intercostal region, no heaves, lifts, or excitement.

Abdomen: Evidence of pain on palpation. Abdomen is soft and protuberant. Abnormal bowel sounds heard.

Back/spine: No evidence of trauma. Evidence of severe pain on pressing. No signs of deformity. No spinal curvature noted.

Extremities, including exam of pulses: Evidence of stiffness and tenderness in all joints. No evidence of swelling of the joints. Lower extremities are atraumatic. No palpable pulses in the upper and lower extremities.

Genitalia/Rectal (female): Hair is evenly distributed on the pubic area. No lesions or masses observed on the external genital area. Evidence of suprapubic pain on palpation. No vaginal discharge or evidence of inflammation.

Neurologic:

 

Mental status: M.L. is attentive. There is evidence of difficulty concentration, impaired memory, and impaired thinking ability.

Cranial nerves: Normal findings in all crania nerves II-XII will abnormalities noted in cranial nerves X and IX responsible for sensation, strength, and gait. Full EOM observed. Evidence of visual fields observed in cranial nerves II-XII.

Motor: Abnormal gait. Affected balance. Limb rigidity observed. Muscle strength diminished in all joints at 1/5 in all joints.

Sensory: Alterations in pain and non-pain signals. Reflexes are 1+ on upper and lower limbs. Pain sensitivity diminished. Evidence of paresthesia.

VIII. Problem list
  • Chronic widespread musculoskeletal pain
  • Constant pain for at least 3 months
  • Severe pain and tenderness in all joints
  • Cognitive difficulties (fibro fog): Characterized by impaired memory, inability to concentrate, and impaired thinking abilities.
  • Other associated symptoms: Extreme fatigue; pain around the head and in either side of the jaws; gastrointestinal problems such as abdominal pain, constipation, and bloating; mental issues such as anxiety and depression; sleep disturbance.
  1. ASSESSMENT
  • Fibromyalgia
  1. Differential Diagnosis
  • Hypothyroidism
  • Bursitis
  • Anxiety

X1. Plan:

  1. Diagnostic (labs etc.)
  • Palpate 18 joint sides in the body. Pain in at least 11 sites confirms the presence of fibromyalgia
  • Complete Blood Count (CBC)
  • Thyroid function tests and a comprehensive metabolic panel
  • Rheumatoid factor test
  1. Medications
  • Advise the patient to continue taking Tylenol
  • Amitriptyline 25 mg taken at bedtime
  1. Referral
  • Psychologist
  • Physiotherapist
  • Orthopedist
  1. Patient Education

Your diagnosis today is fibromyalgia. Fibromyalgia is a medical condition in which a person complains of chronic widespread musculoskeletal pain that has persisted for at least three months. Other associated symptoms that are positive in your case include; impaired memory, inability to concentrate, impaired thinking abilities, extreme fatigue, sleep disturbance, pain around the head and in either side of the jaws, gastrointestinal problems such as abdominal pain, constipation, and bloating, and mental issues such as anxiety and depression.

Risk factors of fibromyalgia include a familial history of the condition and being of a female gender of middle age. Your pharmacological treatments will be 2 tablets of Tylenol every six hours daily and Amitriptyline 25 mg taken at bedtime. Some of the non-pharmacological interventions that you can consider include; cognitive behavioral therapy, exercise, acupuncture, and physical therapy. It is highly advisable that you adhere to the recommended regimen.

Complications associated with fibromyalgia include chronic fatigue, persistent pain, poor sleep quality, and continued psychological distress. You will be referred to a psychologist, a physiotherapist, and an orthopedist for further evaluation. For health promotion, limit stress, sleep for at least 6 hours per night, exercise regularly, and eat balance diet containing all the five food groups including carbohydrates, proteins, vitamins, minerals, as well as fruits and vegetables.

  1. Follow-Up: Visit the clinic for evaluation after two weeks.

References

 

Khurshid, H., Qureshi, I. A., Jahan, N., Went, T. R., Sultan, W., Sapkota, A., & Alfonso, M. (2021). A systematic review of fibromyalgia and recent advancements in treatment: Is medicinal cannabis a new hope?. Cureus13(8), e17332. https://doi.org/10.7759/cureus.17332

Maffei, M. E. (2020). Fibromyalgia: Recent advances in diagnosis, classification, pharmacotherapy and alternative remedies. International Journal of Molecular Sciences, 21,21 7877. doi:10.3390/ijms21217877

Qureshi, A. G., Jha, S. K., Iskander, J., Avanthika, C., Jhaveri, S., Patel, V. H., Rasagna Potini, B., & Talha Azam, A. (2021). Diagnostic challenges and management of fibromyalgia. Cureus13(10), e18692. https://doi.org/10.7759/cureus.18692

Rodríguez-Mansilla, J., Mejías-Gil, A., Garrido-Ardila, E. M., Jiménez-Palomares, M., Montanero-Fernández, J., & González-López-Arza, M. V. (2021). Effects of non-pharmacological treatment on pain, flexibility, balance and quality of life in women with fibromyalgia: A randomised clinical trial. Journal of Clinical Medicine10(17), 3826. https://doi.org/10.3390/jcm10173826

Siracusa, R., Paola, R. D., Cuzzocrea, S., & Impellizzeri, D. (2021). Fibromyalgia: Pathogenesis, mechanisms, diagnosis and treatment options update. International Journal of Molecular Sciences22(8), 3891. https://doi.org/10.3390/ijms22083891

Tzadok, R., & Ablin, J. N. (2020). Current and emerging pharmacotherapy for fibromyalgia. Pain Research & Management2020, 6541798. https://doi.org/10.1155/2020/6541798.

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