A PRACTICAL APPROACH TO FIBROMYALGIA: HISTORY AND PHYSICAL EXAMINATION

The patient most likely to be diagnosed as having fibromyalgia is a women between 25-50 years of age.. Almost all patients with fibromyalgia will have some pain in the head and neck area. The pain is described as tingling, aching, soreness, flowing, and diffuse. Since the disease takes so long to diagnose, most patients suffer from chronic pain syndrome by the time their symptoms are taken seriously and they have trouble localizing the pain to discrete areas. Another common theme in these patients is fatigue. The fatigue is severe, sometimes preventing any movement at all. Sleep in non-restful and not restorative. People wake up feeling like they need eight more hours of sleep. Another frequent complaint is swelling of the hands that is not obvious to the examiner, but the patient is clearly able to discern a difference, regardless of whether the swelling effects the ability to wear jewelry, clothing, and can be shown to not effect the shape and size of the fingers. Forgetfulness and an inability to concentrate and think or plan for long term events is also a hallmark of this condition. This last symptom is called fibrofog by the afflicted and is one of the most bothersome symptoms.

On physical examination exclusion of other conditions is the priority. Besides severe tenderness of the skin and muscle tissue there are few objective findings. Bowel sounds are almost always increased, and there may be mild diffuse abdominal tenderness in varying locations and these sites change during the course of the examination. pharmacy united kingdom

TENDER POINTS AND TRIGGER POINTS

Patients can generally feel and find tender points on their own, and fibromyalgia patients are no exception. Tender points are area of tenderness that can be found in the muscle, muscle tendon junction, bursa or fat pad. Trigger points are areas of muscle that are painful to palpation and usually not noted by the patient until pointed out by the practitioner. Trigger points feel like taut bands of tissue. Both may exist together in patients with fibromyalgia, but it is the tender points that are diagnostic.

DIFFERENTIAL DIAGNOSIS

Fibromyalgia is often self diagnosed with the aid of the internet or friends. Finding a treatable condition in a person who claims to have fibromyalgia can be a tremendous benefit to a patient. Hepatitis, hypothyroidism, hyperparathyroidism, diabetes, hypokalemia, hyponatremia have all been found in people who claim to have self diagnosed fibromyalgia. Sleep apnea can be found even in thin women who are not considered to have the typical body build to have sleep disturbances. Malignancy also needs to be considered and evaluated for before a physician can be comfortable that the person has fibromyalgia.

Workup includes a laboratory analysis of a complete blood count, TSH, Hepatitis panel, ESR, chemistry profile, creatinin kinase and a urineanalysis. If rheumatologic disorders like SLE, PMR, RA and polymyositis need to be considered then an ANA and RF should also be done. Sleep studies are also a useful test, but must be done by a sleep center that evaluates for fibromyalgia, and not just pulmonary problems that arise from sleep disturbances. canada viagra online

Muscle biopsies, EMG’s, MRI’s may be needed to address other issues, but are not useful in all patients suspected of having fibromyalgia.

AGGRAVATING AND ALLEVIATING FACTORS

Fibromyalgia patients do not respond uniformly to external factors. It is generally accepted that cold weather, humid weather or a rapid change in temperature can bring on an exacerbation of fibromyalgia. Lifestyle patterns involving sleep, exercising past the point of exhaustion, anxiety, remaining inactive for long periods of time, missing sleep or meals, and allowing oneself to become severely phys­ically or mentally fatigued can cause a flare-up in the syndrome. Other triggers include surgery, medical illness, hypothyroidism, even the activation/infection of HIV or Lyme disease can trigger fibromyalgia. This is not a universal response and in different populations different responses to these stimulii can be found.

The protective factors are considered to be staying on a strict schedule, living in warm or dry weather and maintaining a moderate activity schedule.

PSYCHOLOGICAL FACTORS/GENETIC FACTORS

Physicians caring for fibromyalgia patients should notice a distinct personality type. Symptoms of anxiety and depression almost always accompany fibromyalgia. This does not make fibromyalgia a psychogenic disorder. Many of the symptoms are part of any syndrome where a person has chronic pain. Cognitive factors and a persons expectations of how they should feel, and what they can expect from the healthcare world are very clear to the patient. When those expectations are not met by their bodies, and from the healthcare world there is disappointment, worry and a sense of having been failed by either their bodies or the medical profession. There is a tendency to discontinue coping strategies quickly and a subsequent anticipation of failure. It is common to hear from a new fibromyalgia patient that they are coming to a physician for help, but they know that you won’t be able to do anything to help them.

Clustering of fibromyalgia has been noted, which has led to a search for genetic factors in this syndrome. While clustering does not confirm a genetic role in fibromyalgia, and environmental factors may be the reason for such findings, it has been noted that twenty six percent of first degree relatives of people with fibromyalgia also have fibromyalgia. The search for a HLA association are ongoing with both positive and negative reports found in the literature.

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