Fibromyalgia Case Studies

Reflective Notes

This case was interesting and was chosen for this SOAP note and discussion. Several things were captured in this learning opportunity. First of all, the assessment piece needed to include all of the potential differentials. I discovered myself relying on patterned learning to recall what areas should this focused exam include. Headaches are broad symptoms that can potentially result from many system alterations and can be related to many differentials. Initially, I considered migraine/tension headache history, acute illness (infection/sinusitis), acute injury (trauma or brain bleed), cerebral abnormality (aneurysm/stroke), and secondary causes related to uncontrolled HTN. I then began to narrow the differentials the most likely diagnosis such as tension-type headache based on the details obtained from the history/physical. Next, I began to consider treatment for tension-type headaches. The area of learning in the case was related to the additional treatment with Lyrica for the headaches. I considered the typical interventions such as rest, non-steroidal anti-inflammatory agents, stress reduction, diet, and trigger recognition. I considered the influence of co-morbid condition management, such as HTN, DM, and obesity. I had not considered that the HA potentially be related to her fibromyalgia (FM). According

According to Burttaro et al., (2013), "tension headaches are described as feeling like a tight band around the head that starts when the person wakes up" (p. 1016). These characteristics describe G. G.'s pain. The differentials such as a migraine, cluster headache, and thyroid dysfunction were ruled out based on the characteristics and presentation. Thyroid dysfunction should be considered contributory and ruled out as a concomitant