A 35-year-old woman with no significant past medical history comes to the physician due to muscle and joint pains over her entire body for the past 6 months. She feels as if she has "the flu" all the time. The patient also experiences fatigue, mental slowness, and occasional headaches. Vital signs are within normal limits. On examination, she has tenderness to gentle palpation over the muscles of her neck, shoulders, and back. There is no synovitis. Laboratory results show normal electrolytes, complete blood count, erythrocyte sedimentation rate, and thyroid function.
Which of the following is the best initial therapy to improve this patient's symptoms?

Question

A 35-year-old woman with no significant past medical history comes to the physician due to muscle and joint pains over her entire body for the past 6 months.  She feels as if she has "the flu" all the time.  The patient also experiences fatigue, mental slowness, and occasional headaches.  Vital signs are within normal limits.  On examination, she has tenderness to gentle palpation over the muscles of her neck, shoulders, and back.  There is no synovitis.  Laboratory results show normal electrolytes, complete blood count, erythrocyte sedimentation rate, and thyroid function.
Which of the following is the best initial therapy to improve this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_993f_de87_853d_9dfd0ffd6950_MD0002_00 This patient's clinical features are most consistent with fibromyalgia (FM). FM presents most commonly in young to middle-aged women, with symptoms such as widespread pain, fatigue, and cognitive/mood disturbances. Patients often have point tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. FM has no specific diagnostic laboratory findings. Revised 2010 American College of Rheumatology criteria base the diagnosis on the widespread pain index and symptom severity scale (rather than trigger point tenderness), which emphasize cognitive problems, fatigue, and severity of somatic symptoms. widespread pain index and symptom severity scale Initial management of FM includes patient education, regular aerobic exercise, and good sleep hygiene. Education should emphasize that FM is a benign condition with a favorable prognosis. Although patients may have increased short-term pain during or after activity, a regular exercise program (eg, aerobic conditioning, strength training, stretching) improves long-term pain. Medications (eg, tricyclic antidepressants) are reserved for patients failing initial measures. There is limited evidence for other approaches, including trigger-point injections, analgesics, and alternative therapies (eg, tai chi, yoga). (Choice B) Acetaminophen and tramadol (alone or combined) are effective in patients who fail to respond to standard management. However, the benefits of other opioids, such as hydrocodone, likely do not outweigh the risks, and current evidence suggests that they may actually worsen pain and functional status. (Choice C) Hydroxychloroquine is effective for treating patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). However, it is not effective for FM. This patient does not have other findings to suggest SLE or RA (eg, malar rash, joint abnormalities). (Choices D and E) High-dose prednisone is effective for giant cell arteritis; low-dose prednisone is used to treat polymyalgia rheumatica. Methotrexate is effective for inflammatory conditions such as rheumatoid arthritis. All of these conditions usually have an elevated erythrocyte sedimentation rate or other inflammatory markers. However, FM is not an inflammatory condition and does not respond significantly to anti-inflammatory or immune-modulating medications. Educational objective: Fibromyalgia commonly presents in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Regular exercise and good sleep hygiene are the foundation of management. __________ References: The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. (http://www.ncbi.nlm.nih.gov/pubmed/20461783) Exercise for fibromyalgia: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/18464301)

A 35-Year-Old Woman with No Significant Past Medical History Comes