Fibromyalgia
Fibromyalgia
Julia Hubel and Stephanie South
University of Cincinnati
Anatomy and Physiology I
Dr. Nestor Hilvano
March 10, 2015
Diagnosis: Fibromyalgia
Chief Complaint: Widespread pain throughout body
Emergency Room Assessment:
A 35 year old female patient arrived in the emergency department complaining of weakness, fatigue, and widespread pain throughout the body, with prominent pain radiating specifically from the trapezius and scapular muscles. Patient states she has been dealing with these issues for approximately seven months, with the pain gradually intensifying. Upon the physician’s assessment, the patient’s vitals are normal, but showing minimal signs of discomfort. Patient is restless; shifting positions intermittently. Inspection of the trapezius and scapular muscles showed diffusion tenderness to palpation, but no rebound tenderness. She showed some tenderness around joints, but no obvious synovitis. Patient shows slight muscle weakness. No signs of swelling, deformities, or erythema present.
Vitals: BP = 125/60, Pulse = 68 bpm, Respiratory Rate = 16, Temperature = 98.3 F, Pain = 5/10
Personal History:
Patient states she is a social smoker, does not drink alcohol or use any recreational drugs. Patient has no know allergies. Exercise is adequate and nutrition is good. Patient has previous diagnosis of irritable bowel syndrome (IBS), depression, and post-traumatic stress disorder (PTSD). PTSD stemming from sexual abuse as a child. Surgical history includes a cesarean section in 2013. Current medications include Prozac (mg), Xanax (mg), and Topamax (mg).
Social History:
Patient lives with husband and their three young children. She works outside the home as a second grade teacher at Brantwood Elementary. She states that caring for her children is difficult sometimes due to the pain and weakness she has been experiencing.
Family History:
Mother is diabetic (Type II), suffers from high blood pressure and high cholesterol. Father is an
Julia Hubel and Stephanie South
University of Cincinnati
Anatomy and Physiology I
Dr. Nestor Hilvano
March 10, 2015
Diagnosis: Fibromyalgia
Chief Complaint: Widespread pain throughout body
Emergency Room Assessment:
A 35 year old female patient arrived in the emergency department complaining of weakness, fatigue, and widespread pain throughout the body, with prominent pain radiating specifically from the trapezius and scapular muscles. Patient states she has been dealing with these issues for approximately seven months, with the pain gradually intensifying. Upon the physician’s assessment, the patient’s vitals are normal, but showing minimal signs of discomfort. Patient is restless; shifting positions intermittently. Inspection of the trapezius and scapular muscles showed diffusion tenderness to palpation, but no rebound tenderness. She showed some tenderness around joints, but no obvious synovitis. Patient shows slight muscle weakness. No signs of swelling, deformities, or erythema present.
Vitals: BP = 125/60, Pulse = 68 bpm, Respiratory Rate = 16, Temperature = 98.3 F, Pain = 5/10
Personal History:
Patient states she is a social smoker, does not drink alcohol or use any recreational drugs. Patient has no know allergies. Exercise is adequate and nutrition is good. Patient has previous diagnosis of irritable bowel syndrome (IBS), depression, and post-traumatic stress disorder (PTSD). PTSD stemming from sexual abuse as a child. Surgical history includes a cesarean section in 2013. Current medications include Prozac (mg), Xanax (mg), and Topamax (mg).
Social History:
Patient lives with husband and their three young children. She works outside the home as a second grade teacher at Brantwood Elementary. She states that caring for her children is difficult sometimes due to the pain and weakness she has been experiencing.
Family History:
Mother is diabetic (Type II), suffers from high blood pressure and high cholesterol. Father is an