CASE
A 38 year-old woman comes to you for her first appointment as her new primary care provider on her new insurance plan. Her main business is to have you fill out her disability papers. She carries a diagnosis of Fibromyalgia and produces a copy of old records from a rheumatologist at another clinic. The records are for many blood tests (inflammatory markers, autoantibodies, CBC, chem, A1c, TFT, Lyme titers), x-rays of the hands and knees, and CT scan of the head. All are normal. The copy of the physician’s notes documents physical exam with 9/9 tender points, otherwise normal. The rheumatologist prescribed amitriptyline then gabapentin, then lyrica. The patient developed side effects or had no response to any of the medicines. The forms ask many questions, which you relay to the patient.
| Question | Response |
| How long can the patient walk without stopping? | 30 minutes |
| How much weight can the patient carry for short distances on a frequent (once every ten minutes) basis? | 15 pounds |
| In a typical day how long can the patient remain in a seated position (with occasional breaks)? | 8 hours |
| If the patient is not working, what prevents him/her from working? | Pain all over |
| In a typical day, how long can the patient be standing or walking? | 4 hours |
| Is the patient able to operate foot and hand controls? | Yes |
| Does the patient take medication which interferes with her ability to concentrate? | No |
| Does the patient have psychiatric or emotional conditions which interfere with working? | No |
Finally, there are some questions asking:
As the primary physician, do you believe the patient is malingering?
Do you the believe the patient is physically able to work?
Do you believe the patient is disabled? If so, for how long?
How do you answer these?
