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A 37-year-old female has been seen for chronic pain management. Since a motor vehicle accident 2 years ago, the pain was limited to her neck and upper back, but it has gradually spread and now she reports diffuse pain that is unrelenting. The pain is interrupting her sleep, and when she awakes, she does not feel rested. “I am exhausted all of the time,” she states. This condition is now having an adverse effect on her work and family life. She has used up all of her allowable time off from work and is concerned that she will lose her job. A physical exam reveals an otherwise healthy-appearing female, and a musculoskeletal exam is positive for tender points at the posterior cervical spine, bilateral shoulders, bilateral elbows, and hips. What is the most likely diagnosis? Outline the further evaluation, including the labs and radiographic imaging. What are the anticipated results of laboratory and radiographic imaging? Outline the plan of care, including follow-up. Support your answer with a minimum of two APRN-approved scholarly resources.
References must be within 5 years
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Step-by-Step Guide
- Introduction and Diagnosis
- Begin by summarizing the patient’s presentation, highlighting key points like chronic, diffuse pain, sleep disturbances, and functional impairments.
- State the most likely diagnosis: Fibromyalgia. Support this by referencing the patient’s widespread pain, tender points, unrefreshing sleep, and lack of abnormal findings on physical examination or imaging.
- Provide a brief explanation of fibromyalgia, mentioning its association with central sensitization and potential triggers like trauma or stress.
- Further Evaluation
- History and Clinical Assessment:
- Expand on the patient’s history, focusing on the onset, progression, and nature of the pain.
- Evaluate for associated symptoms such as fatigue, cognitive difficulties (e.g., “fibro fog”), and mood disorders (e.g., anxiety or depression).
- Laboratory Tests:
- Include tests to rule out other conditions:
- CBC: To assess for anemia or infection.
- TSH: To rule out hypothyroidism, which can mimic fibromyalgia.
- ESR and CRP: To exclude inflammatory conditions like rheumatoid arthritis.
- Rheumatoid Factor (RF) and Anti-CCP antibodies: To rule out rheumatoid arthritis.
- ANA: To exclude systemic lupus erythematosus.
- Anticipated results: All labs are expected to be within normal limits in fibromyalgia.
- Include tests to rule out other conditions:
- Imaging:
- Order imaging (e.g., X-rays, MRI) only if specific red flags are present, such as neurological deficits, unexplained weight loss, or suspicion of structural issues.
- Anticipated results: Imaging would likely be unremarkable in fibromyalgia.
- History and Clinical Assessment:
- Plan of Care
- Non-Pharmacologic Treatments:
- Exercise: Encourage low-impact aerobic activities like walking, swimming, or yoga to improve pain and function.
- Cognitive-Behavioral Therapy (CBT): Address stress and coping mechanisms.
- Sleep Hygiene: Educate the patient on strategies to improve sleep, such as establishing a regular sleep schedule and limiting screen time before bed.
- Pharmacologic Treatments:
- First-line medications:
- Amitriptyline or Nortriptyline: Low doses to improve sleep and pain.
- Pregabalin or Gabapentin: To address neuropathic pain and central sensitization.
- Consider Duloxetine or Milnacipran for pain and coexisting depression or anxiety.
- First-line medications:
- Patient Education and Support:
- Explain the chronic nature of fibromyalgia and the importance of a multidisciplinary approach.
- Provide information on local or online fibromyalgia support groups.
- Non-Pharmacologic Treatments:
- Follow-Up Plan
- Schedule follow-ups every 4–6 weeks initially to assess symptom management, adherence, and response to therapy.
- Monitor for side effects of medications and adjust treatment as necessary.
- Reassess pain levels, functional capacity, and quality of life.
- References
- Use at least two scholarly APRN-approved sources from within the past five years. Examples include:
- Clauw, D. J. (2020). Fibromyalgia: A clinical review. JAMA.
- Häuser, W., et al. (2021). Management of fibromyalgia syndrome. Pain Reports.
- Use at least two scholarly APRN-approved sources from within the past five years. Examples include:
This guide will help you address each section comprehensively while maintaining a logical flow. Let me know if you need further clarifications!
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