A 53-year-old woman comes to the office with a 6-month history of pain and tightness in the neck, posterior shoulders, and buttocks. The pain is aggravated by exertion, stress, and lack of sleep. She also has fatigue and insomnia. The patient has had intermittent constipation but no other bowel or bladder problems or daytime somnolence. Vital signs are normal. Examination shows widespread symmetric tenderness to firm palpation over muscles and bony prominences. Spinal motion is normal. Strength is 5/5 and deep tendon reflexes are 2+ in all extremities. There are no sensory deficits, rashes, or areas of joint swelling or tenderness. Recent laboratory testing shows a normal complete blood count and erythrocyte sedimentation rate. Based on these findings, what is the most appropriate next step in evaluation of this patient?

Question

A 53-year-old woman comes to the office with a 6-month history of pain and tightness in the neck, posterior shoulders, and buttocks.  The pain is aggravated by exertion, stress, and lack of sleep.  She also has fatigue and insomnia.  The patient has had intermittent constipation but no other bowel or bladder problems or daytime somnolence.  Vital signs are normal.  Examination shows widespread symmetric tenderness to firm palpation over muscles and bony prominences.  Spinal motion is normal.  Strength is 5/5 and deep tendon reflexes are 2+ in all extremities.  There are no sensory deficits, rashes, or areas of joint swelling or tenderness.  Recent laboratory testing shows a normal complete blood count and erythrocyte sedimentation rate.  Based on these findings, what is the most appropriate next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ad_5cf6_8f63_619094e62595_MD0005_00 This patient's presentation is consistent with fibromyalgia (FM). FM presents most commonly in young to middle-age women with widespread pain, fatigue, and cognitive/mood disturbances. Patients typically have a fairly normal physical examination except for point tenderness in areas such as the mid-trapezius, lateral epicondyle, costochondral junction, and greater trochanter. Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity scale , rather than trigger point counts, for diagnosis, as the index and scale better emphasize cognitive problems, fatigue, and severity of somatic symptoms. widespread pain index and symptom severity scale FM is a clinical diagnosis and has no specific diagnostic laboratory findings. However, limited laboratory testing is recommended to rule out common conditions that mimic FM, such as anemia (complete blood count) and inflammatory arthropathy (erythrocyte sedimentation rate or C-reactive protein). In addition, hypothyroidism is prevalent in this patient population, and hypothyroid myopathy frequently presents with findings similar to those of FM; a serum assay for TSH is warranted for most patients. Some experts also advise ruling out myositis with creatine kinase, although this is not always needed. In contrast, serologic testing (eg, antinuclear antibody, rheumatoid factor) has low specificity and is not recommended in the absence of additional objective findings (Choice A). (Choice B) Iron deficiency, even in the absence of anemia, increases the risk of restless legs syndrome. This condition can cause impaired sleep, but most patients also have an uncomfortable sensation of needing to move when falling asleep. FM is more likely to cause multiple tender points on examination. (Choice C) This patient has normal muscle strength. In the absence of more specific features or elevated creatine kinase, muscle biopsy is unnecessary. (Choice D) Patients with FM often have sleep problems, and measures to improve sleep hygiene may decrease symptoms. This patient's sleep problems are mild and likely explained by FM, and she has no daytime somnolence or erythrocytosis to suggest sleep apnea or narcolepsy. Educational objective: Fibromyalgia is diagnosed clinically based on widespread musculoskeletal pain, fatigue, disordered sleep, and impaired cognition. Extensive laboratory testing is unnecessary, but a limited evaluation (eg, complete blood count, erythrocyte sedimentation rate, TSH) for common conditions with similar symptoms can be considered. References: Common questions about the diagnosis and management of fibromyalgia. (http://www.ncbi.nlm.nih.gov/pubmed/25884747)

A 53-Year-Old Woman Comes to the Office with a 6-Month