A 45-year-old woman comes to the clinic with a 3-month history of persistent shoulder and back pain and easy fatigability. She also has pain and stiffness in all her muscles that worsens in the morning and evening. She does not participate in any regular exercise because her pain is exacerbated with activity. She works as a computer programmer and reports some difficulty concentrating on her job. Past medical history is significant for depression and gastroesophageal reflux disease, but she is not currently taking any medications. Physical examination shows normal range of motion and 5/5 muscle strength in both upper and lower extremities. Soft tissue tenderness is present at several locations bilaterally above and below the waist. Which of the following is the most likely diagnosis?

Question

A 45-year-old woman comes to the clinic with a 3-month history of persistent shoulder and back pain and easy fatigability.  She also has pain and stiffness in all her muscles that worsens in the morning and evening.  She does not participate in any regular exercise because her pain is exacerbated with activity.  She works as a computer programmer and reports some difficulty concentrating on her job.  Past medical history is significant for depression and gastroesophageal reflux disease, but she is not currently taking any medications.  Physical examination shows normal range of motion and 5/5 muscle strength in both upper and lower extremities.  Soft tissue tenderness is present at several locations bilaterally above and below the waist.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3b62_6c42_9249_f58835687c4c_MD0001_00 Fibromyalgia is a chronic disorder that is characterized by widespread musculoskeletal pain in association with fatigue and neuropsychiatric disturbances (eg, paresthesias, poor sleep, depression, difficulty concentrating). It is most common in women age 20-55. Examination often shows tenderness at characteristic locations in the soft tissues and at bony prominences. The diagnosis can be made in patients with chronic pain and fatigue for >3 months in the absence of physical or laboratory findings suggestive of an inflammatory etiology (eg, synovial swelling, elevated erythrocyte sedimentation rate or C-reactive protein) or other chronic pain syndrome. The precise etiology of fibromyalgia is unknown, but it likely involves abnormal central processing of painful stimuli. Possible contributing factors include genetic predisposition and physical or emotional stressors. Although exercise can temporarily exacerbate the pain of fibromyalgia, gradual incremental aerobic exercise is proven to reduce pain and improve function. Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors modify processing of pain signals and can also be considered in patients with more severe or refractory symptoms. (Choice A) Ankylosing spondylitis is a chronic inflammatory disease of the axial skeleton characterized by progressive pain and stiffness of the spine, sacroiliitis, and positive serology for HLA-B27 in the majority of patients. (Choice B) Dermatomyositis is an autoimmune condition that causes bilateral proximal muscle weakness associated with violaceous eruption on the eyelids and knuckles, and elevated creatine kinase levels. (Choice D) Polymyalgia rheumatica (PMR) is an inflammatory disorder that affects patients age >50 and causes subacute pain and stiffness in the shoulders and hips, weight loss, fever, and malaise. This patient's age, soft tissue tenderness, and neuropsychiatric symptoms are not consistent with PMR but are typical of fibromyalgia. (Choice E) Rheumatoid arthritis causes a symmetric, inflammatory polyarthritis. It typically presents with pain and morning stiffness of the metacarpophalangeal and proximal interphalangeal joints. The affected joints are warm, swollen, and tender on palpation. Educational objective: Fibromyalgia occurs most commonly in women age 20-55 and presents with diffuse musculoskeletal pain, fatigue, and neuropsychiatric disturbances. It is characterized by abnormal central processing of painful stimuli. Although initially painful, aerobic exercise helps to improve pain and functioning in these patients. __________ References: Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/23213512)

A 45-Year-Old Woman Comes to the Clinic with a 3-Month