Fibromyalgia and persistent pain

FIBROMYALGIA AND CHRONIC PAIN TEMPLATE
Chief Complaint:
Persistent widespread pain impacting the neck, shoulders, and lower back, characterized as a continuous dull ache.
History of Present Illness:
Symptoms initiated around 2 years ago. Pain intensity is moderate to severe, rated 7/10 on a pain scale. Pain quality is described as throbbing and burning. Associated symptoms include fatigue, sleep disturbances, and occasional cognitive issues such as memory lapses. Pain worsens with stress and physical activity, and is relieved by rest and warm baths. Previous treatments include NSAIDs and physical therapy, with limited effectiveness.
Past Medical History:
History of hypertension and irritable bowel syndrome. Previously diagnosed with depression.
Medications:
Currently taking ibuprofen 400 mg as needed for pain. Also on sertraline 50 mg daily for depression.
Social History:
Works as a school teacher, currently on part-time status due to pain. Pain significantly impacts daily activities and quality of life, leading to increased stress. Utilizes meditation as a coping mechanism.
Family History:
Mother has a history of fibromyalgia.
Review of Systems:
Musculoskeletal: Reports joint stiffness and muscle tenderness.
Neurological: Occasional headaches.
Psychological: Experiencing anxiety and low mood.
Gastrointestinal: Frequent bloating and abdominal discomfort.
Sleep patterns: Reports difficulty falling asleep and staying asleep.
Physical Examination:
General appearance: Appears fatigued.
Vital signs: BP 130/85, HR 78 bpm.
Musculoskeletal examination: Tender points identified at the neck, shoulders, and hips. Limited range of motion in the lumbar spine. Muscle strength is normal.
Neurological examination: No focal deficits.
Mood and affect: Appears anxious and slightly depressed.
Diagnostic Criteria (for Fibromyalgia):
Widespread pain index (WPI) score: 14
Symptom severity (SS) scale score: 8
Investigations:
Blood tests: CBC, ESR, CRP within normal limits. Thyroid function tests normal.
Imaging studies: Lumbar spine X-ray shows mild degenerative changes.
Assessment:
Primary diagnosis: Fibromyalgia
Secondary diagnoses or comorbidities: Depression, hypertension
Treatment Plan:
Pharmacological interventions:
  Pain medications: Continue ibuprofen as needed.
  Antidepressants: Continue sertraline.
  Sleep aids: Consider melatonin for sleep disturbances.
Non-pharmacological interventions:
  Physical therapy: Referral for tailored exercise program.
  Exercise program: Low-impact aerobic exercises recommended.
  Cognitive behavioral therapy: Referral for CBT to manage stress and anxiety.
  Stress management techniques: Encourage regular meditation and relaxation exercises.
Patient education: Discussed the chronic nature of fibromyalgia and importance of lifestyle modifications.
Referrals: Referral to rheumatologist for further evaluation.
Follow-up:
Next appointment in 4 weeks.
Goals for next visit: Assess response to treatment and adjust plan as needed.