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

to Karapetyan and Manvelyan (2014), "there are strong correlations between FM and tension-type headaches" (p. 42). Without this consideration, treatment with typical headache interventions may not have helped this patient. Also, I had not considered the bariatric consultation. The patient was requesting this referral due to repeated attempts to lose weight.
I feel the interaction was comprehensive. The only thing I would have considered would have been to spend more time discussing her risk for stroke and why it is essential to manage her HTN, DM, and weight. She had multiple risk factors and is at risk. According to Ravenell et al., (2015), patients who are at risk for stroke need to be informed about the symptoms and when to seek emergency care.
Additional data that may have been helpful to gather would be information about her chronic pain and related depressive symptoms. I did not investigate this in the room as it initially did not appear to be related to the chief complaint. It was only after reflection that I considered this as equally important to her chief complaint and considered this after discussion with my preceptor.
Elements of the exam would have included asking questions about her generalized pain control, quality of life, and activities of daily living. According to Arnold, Gebke, and Choy (2016), comprehensive FM management includes an assessment of both pain and depression. Therefore, these additional elements could have been completed.
I agree with the plan of care that my preceptor discussed. According to Horowitz (2015), FM requires "holistic" interventions that are individualized and symptom-based (p. 26). After this reflection, I began to understand that each alteration presents with unique implications and symptoms and our patients are relying on us to put everything together.
Tension Headache
A tension headache was considered due the patients described characteristics, the patient's age upon onset, obesity, HTN, FM, stress, and lifestyle choices (intake fast food/alcohol/Smoking).

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

condition.
The assessment and treatment of tension-type headaches included best practices. According to Becker et al. (2015), the assessment should include a comprehensive evaluation of emergent causes, illness, neurologic alteration, secondary causes, and visual disturbances. Since G. G. did not have the typical symptoms of a migraine (nausea/light sensitivity) the primary diagnosis was the tension-type headache, and this was consistent with the literature (Becker et al., 2015). The interventions included the use of Ibuprofen and Elavil and this was consistent with the headache guidelines (Becker et al., 2015). The steps taken were appropriate and in alignment with best practices. This patient had many potential contributors to the HA and represented a case that involved using experience and intuition to determine the best path for this patient.
Essential Uncontrolled Hypertension
G. G. had risk factors for uncontrolled HTN that included obesity, age, race, and lifestyle choices (diet/inactivity/smoking/alcohol use). Her medication plan was recently adjusted due to her readings remaining elevated despite pharmacotherapy. She was sent to a nephrologist to help with the management of HTN, and further adjustments had been made that included adding a beta-blocker. Before the visit to the nephrologist, she was on an angiotensin-converting enzyme (ACE) inhibitor, thiazide diuretic, and calcium channel blocker that had been maxed dosed which is supported by the evidence (Cryer, Horani, & DiPette, 2016). The nephrologist changed the medications to an aldosterone receptor agonist and beta blocker with is also supported by the research to treat uncontrolled HTN (Ardeleanu et al., 2014). All of the other non-pharmacological interventions need to be escalated to priority with G. G. to prevent disease progression and morbidity.
Obesity
G. G's BMI had many risk factors for obesity, such as genetics, race, age, and lifestyle choices (diet/inactivity). She had attempted several diets and exercise plans without much success and was requesting a bariatric consult. According to Goritz and Duff (2014), a BMI of 37.2 can be considered for surgery in the presence of obesity-related comorbidities. Although, she will need to consider a commitment to adhere to therapeutic lifestyle changes. As a result, these conversations would need to occur.
Summary
G. G. represented an excellent learning opportunity. She presented with a headache, and the plan of care became much larger that initially expected. The assessment and treatment plan was comprehensive and in alignment with best practices. If she is committed to participating in lifestyle changes prevention of disease progression is possible. Without this collaboration with her, she will suffer from debilitating disease progression or death.