Questions about Today's Doctors Visit

Discussion in 'Fibromyalgia Main Forum' started by elastigirl, Oct 7, 2005.

  1. elastigirl

    elastigirl New Member

    My GP has been so great and understanding. Despite both a Nurse Practioner and a Dr. in the same clinic saying I was, "just getting old," and my blood tests look great, he took me seriously enough to see me and dx me with FM (in his opinion, rheumy's do the official dx I believe).

    Part of me is convinced I have CFS. I am tired sooooooo much of the time! I don't have a job. I don't have five kids (just one). Yet I'm tired all of the time. I even have to say "No" to doing fun things, because, guess what? I'm sleeping.

    He is convinced I have FM, not CFS. My impression last time was that he thought I could have CFS, but this time I got the distinct impression he felt the fatigue was solely caused by FM. Does that make sense?

    He recommends LOTS of sleep, we're talking 10-12 hours a day if not more. Yes, it's true, I do better when I sleep like that. But, once the housework/cooking is done, I have no life.

    Again, he has been great. He gave me a cortisol test, a B12 deficiency test, and a couple more tests at my request.

    So I chickened out when it came for asking for a sleep test. He didn't act like he was going to go for it. $$$ you know $$$. Said he'd wants to double my Elavil script to 50mg.

    When I described my constant low grade fever, sore throat, runny nose, itchy eyes, etc., he suddenly mentioned allergies. (My first visit, I was so focused on fatigue that I didn't get to these symptoms.) I do have food sensitivities, but I've never had allergies in my entire life, so that took me be surprise, but if it's true -- it's so much more treatable!

    He's prescribed Allegra and Nasonex. I trust that he knows what he's doing. I see the rheumy next Tuesday.

    Does this make sense? Are the symptoms of CFS similar to allergies? Can FM and CFS symptoms exist without actually having CFS? What makes CFS distinct?

    At least one good thing came of the Allegra script. I took one tablet and am breathing deeper than I have in years. Now I'm so confused....

    One last thing, I did bring up mycoplasma infections. Although the Dr. has heard of them, he's hesitant to do a test, possibly because he's not convinced I have CFS. He says to bring in printouts of information from reliable sources, and he will take a look at it. Any ideas? Is this worth pursuing?
  2. JLH

    JLH New Member

    Fibro Symptoms List


    GENERAL
    ____ Fatigue, made worse by physical exertion or stress
    ____ Activity level decreased to less than 50% of pre-illness activity level
    ____ Recurrent flu-like illness
    ____ Sore throat
    ____ Hoarseness
    ____ Tender or swollen lymph nodes (glands), especially in neck and underarms
    ____ Shortness of breath (air hunger) with little or no exertion
    ____ Frequent sighing
    ____ Tremor or trembling
    ____ Severe nasal allergies (new allergies or worsening of previous allergies)
    ____ Cough
    ____ Night sweats
    ____ Low-grade fevers
    ____ Feeling cold often
    ____ Feeling hot often
    ____ Cold extremities (hands and feet)
    ____ Low body temperature (below 97.6)
    ____ Low blood pressure (below 110/70)
    ____ Heart palpitations
    ____ Dryness of eyes and/or mouth
    ____ Increased thirst
    ____ Symptoms worsened by temperature changes
    ____ Symptoms worsened by air travel
    ____ Symptoms worsened by stress


    PAIN
    ____ Headache
    ____ Tender points or trigger points
    ____ Muscle pain
    ____ Muscle twitching
    ____ Muscle weakness
    ____ Paralysis or severe weakness of an arm or leg
    ____ Joint pain
    ____ TMJ syndrome
    ____ Chest pain



    GENERAL NEUROLOGICAL
    ____ Lightheadedness; feeling "spaced out"
    ____ Inability to think clearly ("brain fog")
    ____ Seizures
    ____ Seizure-like episodes
    ____ Syncope (fainting) or blackouts
    ____ Sensation that you might faint
    ____ Vertigo or dizziness
    ____ Numbness or tingling sensations
    ____ Tinnitus (ringing in one or both ears)
    ____ Photophobia (sensitivity to light)
    ____ Noise intolerance



    EQUILIBRIUM/PERCEPTION
    ____ Feeling spatially disoriented
    ____ Dysequilibrium (balance difficulty)
    ____ Staggering gait (clumsy walking; bumping into things)
    ____ Dropping things frequently
    ____ Difficulty judging distances (e.g. when driving; placing objects on surfaces)
    ____ "Not quite seeing" what you are looking at



    SLEEP
    ____ Hypersomnia (excessive sleeping)
    ____ Sleep disturbance: unrefreshing or non-restorative sleep
    ____ Sleep disturbance: difficulty falling asleep
    ____ Sleep disturbance: difficulty staying asleep (frequent awakenings)
    ____ Sleep disturbance: vivid or disturbing dreams or nightmares
    ____ Altered sleep/wake schedule (alertness/energy best late at night)



    MOOD/EMOTIONS
    ____ Depressed mood
    ____ Suicidal thoughts
    ____ Suicide attempts
    ____ Feeling worthless
    ____ Frequent crying
    ____ Feeling helpless and/or hopeless
    ____ Inability to enjoy previously enjoyed activities
    ____ Increased appetite
    ____ Decreased appetite
    ____ Anxiety or fear when there is no obvious cause
    ____ Panic attacks
    ____ Irritability; overreaction
    ____ Rage attacks: anger outbursts with little or no cause
    ____ Abrupt, unpredictable mood swings
    ____ Phobias (irrational fears)
    ____ Personality changes


    EYES AND VISION
    ____ Eye pain
    ____ Changes in visual acuity (frequent changes in ability to see well)
    ____ Difficulty with accommodation (switching focus from one thing to another)
    ____ Blind spots in vision


    SENSITIVITIES
    ____ Sensitivities to medications (unable to tolerate "normal" dosage)
    ____ Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes, hair sprays)
    ____ Sensitivities to foods
    ____ Alcohol intolerance
    ____ Alteration of taste, smell, and/or hearing



    UROGENITAL
    ____ Frequent urination
    ____ Painful urination or bladder pain
    ____ Prostate pain
    ____ Impotence
    ____ Endometriosis
    ____ Worsening of premenstrual syndrome (PMS)
    ____ Decreased libido (sex drive)




    GASTROINTESTINAL
    ____ Stomach ache; abdominal cramps
    ____ Nausea
    ____ Vomiting
    ____ Esophageal reflux (heartburn)
    ____ Frequent diarrhea
    ____ Frequent constipation
    ____ Bloating; intestinal gas
    ____ Decreased appetite
    ____ Increased appetite
    ____ Food cravings
    ____ Weight gain (____ lbs)
    ____ Weight loss (____ lbs)


    SKIN
    ____ Rashes or sores
    ____ Eczema or psoriasis



    OTHER
    ____ Hair loss
    ____ Mitral valve prolapse
    ____ Cancer
    ____ Dental problems
    ____ Periodontal (gum) disease
    ____ Aphthous ulcers (canker sores)



    COGNITIVE
    ____ Difficulty with simple calculations (e.g., balancing checkbook)
    ____ Word-finding difficulty
    ____ Using the wrong word
    ____ Difficulty expressing ideas in words
    ____ Difficulty moving your mouth to speak
    ____ Slowed speech
    ____ Stuttering; stammering
    ____ Impaired ability to concentrate
    ____ Easily distracted during a task
    ____ Difficulty paying attention
    ____ Difficulty following a conversation when background noise is present
    ____ Losing your train of thought in the middle of a sentence
    ____ Difficulty putting tasks or things in proper sequence
    ____ Losing track in the middle of a task (remembering what to do next)
    ____ Difficulty with short-term memory
    ____ Difficulty with long-term memory
    ____ Forgetting how to do routine things
    ____ Difficulty understanding what you read
    ____ Switching left and right
    ____ Transposition (reversal) of numbers, words and/or letters when you speak
    ____ Transposition (reversal) of numbers, words and/or letters when you write
    ____ Difficulty remembering names of objects
    ____ Difficulty remembering names of people
    ____ Difficulty recognizing faces
    ____ Difficulty following simple written instructions
    ____ Difficulty following complicated written instructions
    ____ Difficulty following simple oral (spoken) instructions
    ____ Difficulty following complicated oral (spoken) instructions
    ____ Poor judgment
    ____ Difficulty making decisions
    ____ Difficulty integrating information (putting ideas together to form a complete picture or concept)
    ____ Difficulty following directions while driving
    ____ Becoming lost in familiar locations when driving
    ____ Feeling too disoriented to drive
  3. JLH

    JLH New Member

    Master Symptom List for CFS, FMS, CMP & Lyme Disease

    Note on Symptoms: many of these are symptoms common to other diseases. Getting a proper diagnosis for CFS, FM, CMP, Lyme, and other tick-borne diseases is as much ruling out other diseases as it is looking at the clues in dozens of tests and the actual physical exam.

    By Melissa Kaplan, The Carousel Network, May/June 2003



    AUTONOMIC NERVOUS SYSTEM / ENDOCRINE / IMMUNE / HORMONE

    Abnormal sensitivity to hot or cold
    Allergies (nasal, other; new, increased or worsening)
    Canker sores (frequent)
    Chills and/or shakes when hungry (may occur instead of feeling hungry)
    Cold hands and feet
    Feeling hot or cold often
    Flu-like symptoms, on-going or recurrent after initial gradual or acute onset; includes mild fever (99.5-101.5 F / 37.5-38.6 C), chills, extreme fatigue after minimal exertion
    Hair loss (alopecia)
    Herpes simplex or shingles rash
    Increased susceptibility to infections
    Low-grade fevers
    Low blood pressure (below 110/70)
    Low body temperature (below 97.5)
    Lymph nodes painful, swollen (in neck; under arms)
    Night sweats (not related to menopause or fever)
    Orthostatic Intolerance (neurally mediated hypotension)
    Reactive hypoglycemia and insulin resistance
    Thirst, increased
    Temperature irregularities; often feeling hot or cold irrespective of actual ambient temperature
    and body temperature; low body temperature (below 97.6 F / 36.4 C)
    Thyroid inflammation (acute thyroiditis; hypothyroidism; Hashimoto's thyroiditis)


    CARDIOPULMONARY / ESPIRATORY / CIRCULATORY

    Cardiac abnormalities (mitral valve prolapse; myocarditis; tachycardia; palpitations;
    dysrhythmia)
    Cough
    Dyspnea (out of breath) or shortness of breath (air hunger) after minimal or no exertion
    Heart attack
    Heart palpitations
    Heart pounds so hard it shakes body, bed
    Pulse skips
    Serious rhythm disturbances of heart
    Sighing, frequent, not related to mental/emotional state
    Stroke
    Vasculitis


    CENTRAL NERVOUS SYSTEM / NEUROLOGIAL / NEUROPATHIC / OTOLOGIC

    Abnormal CAT, MRI, and/or SPECT scans
    Alcohol intolerance
    Aseptic meningitis
    "Brain fog"; inability to think clearly (often referred to as “fibro fog”)
    Difficulty moving tongue to speak
    Diminished or absent reflexes
    Fainting or blackouts; feeling like you might faint
    Headaches (frequent, severe, recurring)
    Hearing fluctuations (sounds fade then return)
    Hearing changes, often from day to day (need to turn up, then down, volume of radio, TV)
    Joint or arthritic pain not relieved by NSAIDs (ie, ibuprofen)
    Libido (decreased)
    Light-headedness, feeling spaced-out
    Migraine headaches
    Muscle twitching
    Noise intolerance
    Paralysis or severe weakness of limb
    Parasthesias (numbness, tingling, crawling, itching sensations) in face, head, torso, extremities
    Photosensitivity
    Radiculitis
    Seizures; seizure-like episodes
    Sensory alterations (hyper- or hyposensitivity) - smell, taste, hearing (noise intolerance)
    Severe muscle weakness
    Syncope (fainting)
    Tinnitus (ringing/noises in one or both ears)
    Touch or weight of clothing on or against body causes discomfort or pain
    Tremors, trembling


    COGNITIVE FUNCTION

    Becoming lost in familiar locations when driving
    Difficulty with simple calculations (e.g., balancing checkbook)
    Difficulty expressing ideas in words
    Difficulty moving your mouth to speak
    Difficulty making decisions
    Difficulty following directions while driving
    Difficulty remembering names of objects
    Difficulty remembering names of people
    Difficulty recognizing faces
    Difficulty following simple written instructions
    Difficulty following complicated written instructions
    Difficulty following simple oral (spoken) instructions
    Difficulty following complicated oral (spoken) instructions
    Difficulty integrating information (putting ideas together to form a complete picture or concept)
    Difficulty putting tasks or things in proper sequence
    Difficulty paying attention
    Difficulty following a conversation when background noise is present
    Difficulty making and/or retrieving memories (long/short-term memory deficits)
    Difficulty understanding what you read
    Easily distracted during a task
    Feeling too disoriented to drive
    Forgetting how to do routine things
    Forgetting the use of common objects (such as, what to do with the shampoo when you are standing in the shower)
    Forgetting how to get to familiar places
    Impaired ability to concentrate
    Losing your train of thought in the middle of a sentence
    Losing track in the middle of a task (remembering what to do next)
    Poor judgment
    Switching left and right
    Slowed and/or slurred speech
    Stuttering; stammering
    Transposition (reversal) of numbers, words and/or letters when you speak and/or speak
    Word-finding difficulty
    Using the wrong word


    DIGESTIVE / HEPATIC

    Bloating; intestinal gas
    Decreased appetite
    Digestive chemicals (acid, enzymes) reduced or absent
    Esophageal reflux; heartburn
    Frequent constipation
    Frequent diarrhea
    Food cravings (especially carbohydrates, sweets)
    Food/Substance intolerance
    IBS
    Liver function impaired; mild abnormalities
    Increased appetite
    Nausea
    Spleen tender or enlarged
    Stomach ache, cramps
    Vomiting
    Weight gain or loss


    EQUILIBRIUM /PERCEPTION

    Bite your cheeks or tongue frequently
    Bump into things frequently
    Difficulty discriminating printed matter despite proper vision correction
    Distances (difficulty judging when driving; when putting things down on surfaces)
    Dizziness or vertigo
    Dropping things frequently
    Dysequilibrium (balance problems)
    Impaired coordination
    Loss of balance when standing with eyes closed
    Perception (not quite seeing what you are looking at)
    Some patterns (stripes, checks) cause dizziness
    Spatial disorientation
    Staggering gait (clumsy walking)
    Words on printed page appear to jump off page or disappear when staring at them


    EYES / VISION

    Acuity changes not related to prescription changes
    Blind spots
    Blurred vision
    Conjunctivitis
    Diminished visual acuity in absence of actual vision change
    Drooping eyelid
    Double vision
    Eye pain
    Flashes of light perceived peripherally
    Optic neuritis or atrophy
    Oscillopsia (image jiggles)
    Prescription changes more frequently
    Pressure sensation behind eyes
    Red and/or tearing eyes
    Retinal damage
    Slowed accommodation (switching focus from far to near, near to far)
    Spots or floaters not related to migraines
    Swelling around eyes
    Uveitis and/or iritis
    Wandering or lazy eye


    HEAD / NECK / MOUTH
    Bell's palsy (facial paralysis, one or both sides)
    Bruxism (grinding/clenching teeth)
    Canker sores
    Dizziness when you turn your head or move
    Dry chronic cough
    Dry eyes, nose and mouth (sicca syndrome)
    Pain in ears, palate, gums
    Periodontal disease
    Prickling pain along skin of jaw
    Problems swallowing, chewing
    Runny nose in absence of cold, allergies
    Sinus infections
    Sore spot on the top of your head
    Temperomandibular Joint Syndrome (TMJ)
    Unexplained toothaches
    Xerostoma (dry mouth)


    MUSCULOSKELETAL

    Arthritic pain that migrates from joint to joint
    Carpal tunnel syndrome
    Frozen shoulder
    Intermittent joint swelling
    Joint aches (arthralgia)
    Joint pain, without redness or swelling
    Loss of tone
    "Lumpy, bumpy" long muscles
    Morning stiffness
    Muscle aches (myalgia)
    Muscle pain, stiffness, weakness
    Pyriform muscle syndrome
    Reduced range of motion
    Stiff neck
    Writing causes pain in hand, arm shoulder


    PAIN SYMPTOMS

    Abdominal pain
    Chest pain
    Debilitating generalized pain (arms, neck, shoulders, hips, legs, etc.)
    Muscle pain (all over your body)
    Painful tender points (FMS: 11 out of 18 tender points)
    Shooting or stabbing pains

    PSYCHOLOGICAL SYMPTOMS / MOOD / EMOTIONS

    Abrupt/Unpredictable mood swings
    Anxiety or fear for no obvious reason
    Appetite increase/decrease
    Decreased self-esteem
    Depression or depressed mood
    Feeling helpless and/or hopeless
    Feeling worthless
    Frequent crying for no reason
    Helpless/Hopeless feelings
    Inability to enjoy previously enjoyed activities
    Irritability; over-reaction
    New phobias/irrational fears
    Panic attacks
    Personality changes (labile, irritable, anxious, confused, forgetful)
    Phobias (irrational fears)
    Rage attacks; anger outbursts for little or no reason
    Suicidal thoughts or suicide attempts


    SENSITIVITIES

    Acute or abnormal reactions to medications
    Alteration in taste, smell, and/or hearing
    Chemicals (alcohol, medications, perfumes, smells; lower tolerance for)
    Food sensitivities
    Increased perception of and sensitivity to noise
    Light sensitivity
    Sensitivity to odors (able to detect and/or react in concentrations far lower than before and that healthy people cannot smell)


    SKIN / NAILS

    Abnormal scarring
    Acrodermatitis Chronica Atrophician
    Blotchy or mottled skin
    Bruise easily
    Bruises may take longer to appear, and/or longer to fade
    Bull's-eye (Erythema migrans) on light skin (resembles a bruise on dark skin)
    Dermographia (minor scratch pressure on skin leaves vivid red welts)
    Dry, itchy skin
    Easily scar
    Eczema or psoriasis
    Fragile nails
    Frequent skin irritations
    Lymphadenosis benigna cutis
    Nails that curve under or downward
    Overgrowing connective tissue (ingrown hair, adhesions, thickened/split cuticles, cysts, fibroids)
    Painful skin (abnormal/excessive pain when scratched or rubbed)
    "Paper" skin (feels fragile, tissue-thin when rubbed)
    Rashes on body, face
    Vertical ridges or beads in nails


    SLEEP SYMPTOMS

    Abnormal brain activity in stage 4 sleep
    Altered sleep/wake patterns (alert/energetic late at night, sleepy during day
    Difficulty falling asleep
    Difficulty staying asleep (frequent and/or prolonged awakenings)
    Hypersomnia (excessive sleeping)
    Myclonus (restless leg syndrome; occasional jerking of entire body)
    Nightmares (frequent, extremely vivid and/or disturbing)
    Unrefreshing/Non-restorative sleep


    UROGENITAL / REPRODUCTIVE

    Decreased libido
    Discharge from breast or galactorrhea
    Endometriosis
    Frequent urination
    Incontinence
    Impotence
    Infant: premature; low birth weight; low muscle tone; failure to thrive
    Interstitial cystitis
    Miscarriage or stillbirth
    Painful intercourse
    Painful urination or bladder
    Pelvic and/or rectal pain
    Prostate pain
    Swollen testicles
    Other symptoms worsen before start of menstruation
    Worsening of PMS


    OTHER

    Abnormal or other changes in sweating
    Activity level reduced to less than 50% of pre-onset level
    Burning sensation (internal and/or external)
    Cancer
    Changed voice
    Changes in sweat odor/body odor
    Delayed reaction to over activity/exertion (onset 24-48 hours after exertion)
    Electromagnetic (EM) sensitivity (electrical storms, full moon, affect function of electrical devices)
    Fatigue, prolonged, disabling, made worse by exertion or stress
    Fibrocystic breasts
    "Galloping" cholesterol and triglycerides
    Hair loss (not related to age, hormones, diet, medication)
    Hands hurt excessively when put in cold water
    Handwriting changes, altering signature and/or other writing
    Hoarseness
    Painful, weak grasp that gives way/lets go
    Periods of concentrated thinking causes physical and mental exhaustion, increases pain
    Sore throat
    Swelling/Idiopathic edema (fluid retention syndrome)
    Symptoms worsened by extremes of temperature (hot, cold), stress, and/or air travel
    Symptoms change focus from time to time, like infection is moving through the body
    Thickened mucus secretions (nose, bowel, vaginal)
    Thickened "sleep" around eyes in mornings
    Very attractive to biting flies and mosquitoes
    Weight changes (usually gain)


    COMMON CO-INFECTIONS AND DISORDERS

    Babesiosis
    Cytomegalovirus (CMV)
    Epstein-Barr virus (EBV)
    Ehrlichiosis
    Herpesvirus
    HHV6
    Iron deficiency
    Mercury or other metal toxicity
    Mycoplasma
    Systemic mold and/or mold sensitivities
  4. Empower

    Empower New Member

    Sometimes I think I don't have CFS but horrible allergies that are really bringing me down.

    I get so confused about this

    I DO have FMS, not sure about the CFS, but have ALOT of fatigue and exhaustion

    Just not sure if the exhaustion can be blamed on the FMS??
  5. elastigirl

    elastigirl New Member

    I have a lot of symptoms from both categories. Almost feel guilty saying that because today is a 'good' day -- but as I learned a long time ago, a good day is just a good day, not a guarantee of good health tomorrow.

    Perhaps my doctor feels because fatigue is on the FM list, it's enough to say you have FM? However, my SIL finds this slightly offensive because she deals with more pain/less fatigue while I deal with more fatigue/less pain.

    And from what I've read on this board, people with straight FM do seem to be in a lot more pain than those with just CFS/ or CFS/FM. (Unless I've gotten the wrong impression.)

    I do believe that I have CFS just because my pain is limited to bad or fair days. On a good day, I have virtually no pain. But I'm tired most of the time, and when I'm not tired, I can get tired very quickly with very little exertion,

    However, since my new meds are relieving my sore throat, runny nose, itchy eyes, etc., I have to believe that my dr. is onto something regarding allergies.

    So I guess I must conclude this:

    I have self-diagnosed CFS and dr. diagnosed FM. How does that sound :)?
    [This Message was Edited on 10/10/2005]
  6. KelB

    KelB New Member

    I do like those lists and I've referred to them in the past - I find them helful for remembering symptoms that I forget when under pressure.

    BUT... how on earth can cancer be classed as a "symptom" of CFS or FM? Is it an established fact that we have a greater incidence of cancer than the general population? If so, what sort(s)?
  7. rileyearl

    rileyearl New Member

    It sounds like your doctor means well, but is not familiar enough with the current knowledge around fms or cfs. You might see if he will refer you to an endocrinologist to have your blood really tested for a number of things including:

    Thyroid--T3 specifically
    Hormone levels
    viruses
    yeast
    insulin
    glucose
    vitamin deficiencies
    and many more

    I believe there is a very thorough list of what is checked at the Fibromyalgia and Fatigue Centers on a thread here. You might do a search for FFC. You will see that the scope of what needs to be investigated to make you feel better is way beyond what your doc is doing now.

    I don't know if it matters what the diagnosis is, whether it's CFS or FMS. Many of us have both. What matters is that whatever is off balance in your body be addressed. No cure, but your quality of life can be good.

    I'm working toward that goal myself. I'm in the very early stages. Taking a shower is a monumental task. But slowly I gain energy and even have a day now and then when I don't have to take any pain pills.

    Good luck on your quest for health!

    Francie
  8. malgal

    malgal Member

    Hi-
    Allopathic medicine is a blessing, but Chinese medicine and other alternative Dr.s and practitioners are less concerned with naming the disease and more interested in treating the overall cause and symptoms. Allergies/sensitivites can be caused by weakened immune system AND visa versa. Which came first?

    I COMPLETELY understand your need for a definitive diagnosis! But, just in case you don't get a "name" for your distress (and it MAY change from Dr. to Dr.), know that you're not alone and I think you'll fare better by looking into EVERY possibility (mycoplasma, hormones, allergies, etc.) in the way that you are.
    Kudos to your Dr. for respecting YOUR input and offering to read the info.you bring to him! That's not entirely common.
    I LOVE (read sarcasm here) when they say these symptoms are due to normal aging. When I was first ill w/ lupus at 23, my Dr. said "Well, you're not 19 anymore."!! Unbelievable!
    Best wishes for good health!
    Malgal
  9. pirtpain

    pirtpain New Member

    dear elastigirl, i was once told that the difference between CFS & FMS is that CFS has more fatigue than pain and that FMS has more pain than fatigue. I have had FMS for 11 years and believe me fatigue is a really big problem and I beleive that all FMS patients have CFS.(only my thought). Allergies also started around that time and I took Allegra. Also I know that there are no tests available for DX of fibro. and your rheume. will fill you in on the trigger points. GOOD LUCK!!!

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