A 72-year-old woman comes to the physician because of aching and stiffness of her neck and shoulders for the past several weeks. This stiffness lasts for 1-2 hours after rising in the morning. She has tried ibuprofen without relief and has also experienced increasing fatigue for 4-6 weeks. She has no visual changes, headaches, other joint complaints, fever, or chills. Her weight is stable. The patient has osteoporosis, hyperlipidemia, type 2 diabetes mellitus, and hypertension. Current medications include metformin, chlorthalidone, lisinopril, atorvastatin, and calcium and vitamin D supplements.
On physical examination, she appears to be in no acute distress. Her temperature is 37.1 C (98.8 F), pulse is 84/min, blood pressure is 130/84 mm Hg, and respiratory rate is 16/min. There is some limitation in range of motion of her shoulders and neck. There is no cervical muscle tenderness, no upper or lower extremity proximal muscle weakness, and no joint swelling or redness.
The patient's laboratory results are as follows:

Which of the following is the most likely cause of this patient's condition?

Question

A 72-year-old woman comes to the physician because of aching and stiffness of her neck and shoulders for the past several weeks.  This stiffness lasts for 1-2 hours after rising in the morning.  She has tried ibuprofen without relief and has also experienced increasing fatigue for 4-6 weeks.  She has no visual changes, headaches, other joint complaints, fever, or chills.  Her weight is stable.  The patient has osteoporosis, hyperlipidemia, type 2 diabetes mellitus, and hypertension.  Current medications include metformin, chlorthalidone, lisinopril, atorvastatin, and calcium and vitamin D supplements.
On physical examination, she appears to be in no acute distress.  Her temperature is 37.1 C (98.8 F), pulse is 84/min, blood pressure is 130/84 mm Hg, and respiratory rate is 16/min.  There is some limitation in range of motion of her shoulders and neck.  There is no cervical muscle tenderness, no upper or lower extremity proximal muscle weakness, and no joint swelling or redness.
The patient's laboratory results are as follows:

Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec193a_9912_1851_853d_2f113ee544c7_MD0002_00 This patient, with pain and stiffness of proximal muscles associated with an elevated erythrocyte sedimentation rate (ESR), has typical features of polymyalgia rheumatica (PMR). PMR is a disorder of unknown cause that occurs in approximately 1% of the population age >50. The ESR is >40 mm/h in 70%-90% of patients, and the C-reactive protein (CRP) is increased >10 mg/L in more than 90% of individuals. Imaging is usually not helpful for diagnosis. Administration of 15-20 mg/day of prednisone provides rapid resolution of symptoms; lack of a prompt response should call the diagnosis into question. Although there are no specific laboratory studies to confirm the diagnosis of PMR, age of onset, elevation of ESR, and rapid response to prednisone will differentiate PMR from other myopathies. other myopathies (Choice A) Diabetic amyotrophy typically presents as an acute asymmetrical pain followed by gradually worsening proximal lower extremity and back weakness, autonomic failure, and weight loss. This patient's lack of lower extremity weakness makes this diagnosis less likely. (Choice B) Fibromyalgia presents with widespread musculoskeletal pain, fatigue, stiffness, and aching with characteristic tender points. Fibromyalgia usually has a normal CRP and ESR, and while prevalence increases with age, initial onset usually occurs in younger patients. (Choice C) Hypothyroid myopathy is characterized by myalgias, weakness, and elevated creatine kinase (CPK). This patient's mild elevation of TSH is more likely due to subclinical hypothyroidism, which is usually not associated with her degree of symptoms. (Choice D) Statin myopathy is characterized by myalgias with proximal muscle weakness and elevated CPK. This patient has an elevated ESR with normal strength, which is more consistent with PMR. Educational objective: Polymyalgia rheumatica causes proximal muscle aching and stiffness in elderly patients and responds rapidly to low-dose prednisone. __________ References: Polymyalgia rheumatica and giant cell arteritis (http://www.ncbi.nlm.nih.gov/pubmed/18640460) Polymyalgia rheumatica: A 10 year epidemiologic and clinical study (http://www.ncbi.nlm.nih.gov/pubmed/6982645)

A 72-Year-Old Woman Comes to the Physician Because of Aching