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What’s the Diagnosis?

Case of the Month

The New Physician September 2014

A young woman with progressively worsening fatigue, generalized pain and memory problems 

A 29-year-old woman is referred to a rheumatologist for multiple joint and muscle pain, back pain, and increasing fatigue. Her wrists are painful at the end of the day whenever she performs repetitive movements as a research assistant. Her symptoms started over five years ago with sudden onset of sharp, left shoulder pain. She noted gradual radiation of pain to both arms and worsening of symptoms with cold temperature. Her primary care provider recommended over-the-counter analgesics, which resolved the symptoms. 

The shoulder pain has returned and is associated with diffuse muscle pain. There is also occasional bilateral hip pain and ascending numbness from the feet whenever the patient sits down for prolonged periods. The numbness usually resolves upon standing up. She has become increasingly fatigued and has trouble falling asleep and staying asleep. The patient also reports difficulty with memory and concentration, as well as feelings of depression. 

The medical history includes well-controlled asthma, eczema, seasonal allergies, and endome- triosis. Her medications include albuterol, Dulera, Allegra, Tylenol, and a cortisone cream. 

On physical exam, the patient is found to be a thin, tall woman in no acute distress. Her vital signs are normal. Cranial nerves are grossly intact, and pupils are 3 mm, equal, and reactive bilaterally. Her reflexes are 2+ throughout. Her strength is 4/5 in the upper extremities and 5/5 in the lower extremities. Her gait and range of motion for all extremities are normal. There are no deformities, swelling, or erythema over the joints. The exam is remarkable for extreme tenderness to palpation when pressure is applied over multiple areas of the body, including the occiput; the fourth through sixth intertransverse spaces of the cervical spine; bilaterally down the scapular, supraspinatus and trapezius muscles; and bilaterally on the medial aspect of both knees. 

The patient’s complete blood count, basic metabolic panel, and urinalysis are unremarkable. Her erythrocyte sedimentation rate is 26 mm/h (normal, 0-20 mm/h); C-reactive protein, 0.5 mg/dL (normal, 0.0-0.8 mg/dL); thyroid stimulating hormone, 4.0 μU/ mL (normal, 0.5-5.0 μU/mL); and free thyroxine and free triiodo- thyronine, within normal limits. Her creatine kinase is normal; antinuclear antibody titer is 1:160 (low-positive range = 1:40 to 1:60); and rheumatoid factor is positive. 

What is the diagnosis?

A. Rheumatoid arthritis 

B. Systemic Lupus Erythematosus 

C. Ankylosing Spondylitis 

D. Fibromyalgia 

E. Myositis 

F. Hypothyroidism

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