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Life Threatening? No
Write-up: Had asthma. HPV shots (9/23/06, 11/24/06, 7/5/07). 1/07 tired, chills, dizzy, stomach ache, sick for one week saw doctor. Addtional appts for body ache, dizzy, vomitting, no energy through 2/07. 3/07 exhausted, sore throat, body aches, sinus. 5/07 chronic fatigue & referred to specialist. 7/26/07 specialist diagnosed fibromyalgia. 9/06 - 2/08 had 13 medical appts. 3/08 passed out in shower, possibly from medication, emergency room treatment. Through 7/08, multiple specialist appts for treatment and pain management. 08/21/2008 MR received from PCP. Seen 11/24/06 for HPV#2. Asymptomatic at that time. Frequent OVs beginning 2/9/07 with c/o feeling sick x 1 week-dizzy, H/A, belly pain, tired, chills-hot and cold, nausea, vomited x 2. PE (+) for exudate on tonsils, swollen lymph nodes in neck. Assessment: Fatigue. Seen again 2/15, 2/21, 2/27 for same sx. Assessment: Chronic Fatigue, Achiness. Myositis. OV 3/22/07 with c/o sore throat. Hyperreflexia noted on exam. Assessment: Healing myositis, r/o Guillain Barre. H/A, Tiredness. Pharyngitis. Seen 5/9 now dx CFS 2'' to post-viral. R/O Fibromyalgia/COD. WCC 7/5/07 with HPV#3. Seen 3/18/08 in f/u to ER for passing out in shower with head trauma/chipped teeth. 4 episodes that day. Lacerations to chin, knee, head. Dx: Syncope. F/u 3/20/08 feeling exhausted, sore w/ H/A. 5/6/08 Dx: Croup, Pharyngitis. 7/3/08 WCC Dx: Fibromyalgia. 11/13/08 Consultant records received from Rheum. First seen in June 2007 and dx with fibromyalgia. OV 2/13/08 with report of worsening sx of malaise, fatigue, difficulty sleeping and H/A. PE (+) for joint pain, back pain, myalgias, neck pain, morning stiffness. Seeing Pain Mgmt and psych for CBT. Seen 4/17/08 in f/u for drop seizure, preceded by nausea and followed by amnesia of event, ?2'' to Elavil. Reports muscle pain and daily occipitoparietal band-like H/A. OV 7/30/08 with improving sx. 1/26/2010 Headaches, body pain, physical weakness, loss of stamina. These symptoms are ongoing and have resulted in patient making many life changing actions.
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