Technical Information: Guidelines for the Diagnosis and Treatment of Fibromyalgia.

Edited By: Gregory C. Gardner, M.D.
Last updated Friday, January 07, 2005

Approach to the patient with suspected fibromyalgi

History/ROS

Important features for history: Core symptoms

• Widespread pain for 3 months (refer to pain diagram)
• Exercise intolerance (Do you feel better or worse after more than usual activity?)
• Fatigue (Do you run out of energy during the day? If so what time?)
• Sleep disturbance (Do you awake rested or tired? Is regular sleep interrupted repeatedly? Disturbing nocturnal myoclonus or restless legs?)

Associated symptoms

• Headaches
• Bowel irritability (constipation alternating with diarrhea)
• Pelvic pain
• Low back pain
• Non-dermatomal parathesias (i.e. whole arm or leg tingles)

Query mood disorders

• Family history of mood disorders
• Personal history of anxiety/depression
• Current mood
• Childhood/adult history of abuse/neglect
• Current stressors

Mimics

• Hypothyroid ROS (i.e. cold intolerance, weight gain, skin dryness, etc…)
• Hypercalcemia (i.e. bones, stones, groans)
• Anemia (heavy periods, dietary habits, previous CBCs)
• Sleep apnea (AM headaches, sleep while at desk or chair during day, sleep partner report)
• Inflammatory arthritis (AM stiffness improves with exercise, joint swelling)

Examination

Focus on positives of history/ROS and possible medical mimics plus:

• Evaluate for joint swelling/ROM
• Muscle weakness (true weakness vs giveway)
• Tenderpoint examination

Basic laboratory tests

• CBC
• ESR
• Basic chemistry panel including calcium
• TSH
• +/-CPK
• +/- Hepatitis C

ESR can be mildly elevated in people who are heavy and remember that the upper limit of ESR is (age + 10)/2 for women and age / 2 for men.

DO NOT check rheumatoid factor or ANAs without a high degree of suspicion for an autoimmune illness, as the false positive rate is sufficiently high to forever label patients incorrectly. Remember that ANAs of titer 1:40 or 1:80 are rarely of any clinical significance.

Surgery for arthritis at the University of Washington

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