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Life Threatening? No
Write-up: This patient had severe generalized fatigue, pain, numbness at many areas of her body; chronic muscle spasms, soft tissue swelling. Diagnosed with fibromyalgia / CFS. The 60 day follow-up states fibromyalgia and chronic fatigue. Per doc 214743, chronic muscle pain, fatigue, disabled, unable to move now for 2 years patient was able to work before. The follow up received on 6/13/01 states, "the pt basically has the same complaints she had last time she was in. Unfortunately, other than for the sleep study and neurologic evaluation by Dr, none of the tests that were ordered at hospital were actually performed. The pt still has chronic fatigue as well as numerous musculoskeletal type pain, most notably in the neck and back. She still has trouble swallowing from time to time, however, she does not wish to undergo work up for this at this time. She has not had fever or headaches. She claims there is some element of depression, although she feels this is probably due to the way she feels. Impression: fibromyalgia, history of thyroid nodule, dysphagia, diffuse back pain most notably affecting the C-spine secondary to fibromyalgia/? concomitant degenerative joint disease or other etiology, allergic rhinitis, status post ablation of accessory pathway for Parkinson-White syndrome, menorrhagia/anemia/stopped iron due to gastirc upset, hypotension on the past couple of visits. Endocrinologic evaluation was recommended to rule out adrenocortical insufficiency. Plan: previously recommende tests will once again be ordered. Encocrinologic evaluation is once again recommended. Check labs. Begin Desipramine 1/2 of 25mg tablet qhs for a week and then 25mg tablet qhs thereafter. Reevaluate in a few weeks or prn." Missing vaccine informaton not available. Follow up: patient states she is permanently disabled, unable to work. Still with symptoms of severe fatigue, and generalized body pain and numbness, mostly on left side of her body.
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