CLOSE[X]Select Patient:
- Chloe
- Annelise
- Maria
- Elizabeth
- Nigel
Select Patient Information:
- Patient Case Study
- Patient Evaluation & Diagnosis
-
Chloe
"I had a car accident a year ago. I was taken to the emergency room, but the doctors there said I had no serious injuries, just heavy bruising. I never really felt like I recovered from the accident, though. The bruises went away, but the achy feeling and the fatigue I experienced are still there. My older sister says she felt that way all the time until her doctor diagnosed her with fibromyalgia and treated her."
Review of symptoms
- Negative
Previous medical history
- No surgery
- No hospitalizations
Chloe
History of present illness
- 30-year-old waitress presents with 2-year history of pain in neck and shoulders, which worsened after a car accident one year ago
- Has felt "achy all over" since a car accident and "is tired all the time"
Physical examination
- Physical exam normal
- Palpated tender points following established fibromyalgia diagnostic guidelines [link to Tender Point Poster download from Tender Point Diagnosis Kit], 12 of eighteen were painful
- Blood tests rule out other conditions
Laboratory examination
Blood Test Result
Complete blood count
Within normal limits
Liver function test
Within normal limits
Tsh, free T4
Within normal limits
CPK
Within normal limits
Erythrocyte sedimentation rate
Within normal limitsDiscussion of findings
- Normal blood tests
- Pain in at least 12 of the eighteen diagnostic tender points
- Pain above and below the waist and on both sides of the body, in addition to axial skeletal pain
- During consultation, patient was asked in more detail about her family medical history and sister’s diagnosis and treatment
Diagnosis
- Fibromyalgia in its earliest stage, triggered by stress in a previously sensitized person
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Annelise
"I've been diagnosed with osteoarthritis to explain my chronic pain and fatigue symptoms, but I still have these other unresolved symptoms. I am feeling ongoing pain. I ache all over, deep in the muscles. It seems like I can't get any peace, and I can't get rid of the pain. It feels like it's been going on for years."
Review of symptoms
- Ongoing widespread pain, drowsiness, fatigue, and some constipation
Previous medical history
- No surgery
- No hospitalizations
Annelise
History of present illness
- 42-year-old office worker diagnosed with osteoarthritis
- She has recently switched PCPs
- She has a 5-year history of dull, throbbing pain in shoulders, hips, and knees; fatigue; inability to sleep through the night; and poor quality of sleep.
Current physical examination
- Digital palpation of tender points following established fibromyalgia diagnostic guidelines [link to Tender Point Poster download from Tender Point Diagnosis Kit], 5 12 of eighteen were painful
Laboratory examination
Blood Test Result
Complete blood count
Within normal limits
Liver function test
Within normal limits
Tsh, free T4
Within normal limits
CPK
Within normal limits
Erythrocyte sedimentation rate
Within normal limitsDiscussion of findings
- Normal blood tests except hormones indicate perimenopause
- Widespread pain despite treatment
Diagnosis
- Fibromyalgia
- Depression
- Perimenopause
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Maria
"I feel very tired at times. Sometimes I am so tired it feels like I hit a wall. I just have no energy. I also have pain—some days are better than others, but the pain is nearly always there. When I get stressed out I get sick to my stomach. Lately, I have been having episodes of diarrhea."
Review of symptoms
- Constipation, drowsiness, and fatigue
Previous medical history
- No surgery
- No hospitalizations
Maria
History of present illness
- 23-year-old university student presents with 2-year history of a low-grade ache in her neck, shoulders, and hips, accompanied by intermittent problems with interrupted sleep and poor sleep quality.
- Additionally, she reports that she has had intermittent nonbloody diarrhea, bloating, and fatigue for more than a year. She was referred to a gastroenterologist six months ago for her recurring GI symptoms.
- A colonoscopy and gastroscopy were performed. Results were normal.
Current physical examination
- A febrile, exhausted young woman in no acute distress
- Normal abdominal and pelvic exam
- Normal joint and neurological exam
- Digital palpation of tender points following established fibromyalgia diagnostic guidelines [link to Tender Point Poster download from Tender Point Diagnosis Kit], fourteen of eighteen were painful
Laboratory examination
Blood Test Result
Complete blood count
Within normal limits
Liver function test
Within normal limits
Tsh, free T4
Within normal limits
CPK
Within normal limits
Erythrocyte sedimentation rate
Within normal limitsDiscussion of findings
- Maria is experiencing pain in fourteen of eighteen tender points
- Her blood tests rule out thyroid disorders and chronic inflammatory states
- She has no muscle inflammation or damage on physical exam
- Her gastroenterologist confirmed a coexisting diagnosis of irritable bowel syndrome (IBS)
Diagnosis
- Fibromyalgia
- Irritable bowel syndrome (IBS)
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Elizabeth
"I have this aching pain that never seems to go away, I'm always tired, and lately, I have been really depressed. I wish I knew what was wrong with me."
Review of symptoms
- Less frequent menstrual periods (q 6 weeks), 2-kg weight gain over the past year
Previous medical history
- No surgery
- Two normal childbirths
- History of depression—not currently on an antidepressant
- Chronic pain—treated with muscle relaxant and NSAID prn
Elizabeth
History of present illness
- 55-year-old housewife and mother of 2 presents with a long history of constant aching in her neck, shoulders, and knees, and depressed mood with fatigue and anhedonia. She reports that for twenty years she has struggled with the neck, shoulder, and knee pain, as well as fatigue, trouble getting to sleep, difficulty concentrating, and intermittent bouts of depression.
- Additionally, she reports that she has had intermittent nonbloody diarrhea, bloating, and fatigue for more than a year. She was referred to a gastroenterologist six months ago for her recurring GI symptoms.
- A colonoscopy and gastroscopy were performed. Results were normal.
Current physical examination
- A febrile, exhausted young woman in no acute distress
- Normal abdominal and pelvic exam
- Normal joint and neurological exam
- Digital palpation of tender points following established fibromyalgia diagnostic guidelines [link to Tender Point Poster download from Tender Point Diagnosis Kit], fourteen of eighteen were painful
Laboratory examination
Blood Test Result
Complete blood count
Within normal limits
Liver function test
Within normal limits
FSH, LH, estradiol, total estrogen
Perimenopause profile
Tsh, free T4
Within normal limits
CPK
Within normal limits
Erythrocyte sedimentation rate
Within normal limits
Blood calcium
Within normal limits
Vitamin D
Within normal limitsDiscussion of findings
- Maria is experiencing pain in fourteen of eighteen tender points
- Her blood tests rule out thyroid disorders and chronic inflammatory states
- She has no muscle inflammation or damage on physical exam
- Her gastroenterologist confirmed a coexisting diagnosis of irritable bowel syndrome (IBS)
Diagnosis
- Fibromyalgia
- Irritable bowel syndrome (IBS)
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Nigel
"I was always achy, and sometimes I hurt so much I could barely walk. I have had trouble sitting for long periods at work and using my computer because of the pain. Recently, I have been unable to come into work at all. I knew there was something wrong with me, but I wasn't sure what."
Review of symptoms
- Trouble sleeping through the night for almost a year
Previous medical history
- No surgery
- No hospitalizations
- Sleep disturbance treated with hypnotic for 6 months
Nigel
History of present illness
- 46-year-old office worker presents with 10-year history of pain in back, shoulders, hips, and knees that has recently worsened.
- He reports that he feels "achy all over."
- On a daily basis for the past month he has had so much pain in his hips and knees that he has had trouble getting out of bed in the morning.
- He has tried muscle relaxants for 6 months with no pain relief.
- Recently he was given steroid injections in his knees, which provided temporary relief.
- A recent visit to his PCP to request pain medication resulted in a referral to a rheumatologist, which led him to this current consultation.
Current physical examination
- Physical exam within normal limits
- Digital palpation of tender points following established fibromyalgia diagnostic guidelines [link to Tender Point Poster download from Tender Point Diagnosis Kit], seventeen of eighteen were painful
Laboratory examination
Blood Test Result
Complete blood count
Within normal limits
Liver function test
Within normal limits
B27 HLA group
Normal
CPK
Within normal limits
Erythrocyte sedimentation rate
Within normal limitsDiscussion of findings
- Normal blood tests
- Pain in seventeen of eighteen tender points
- Pain in above and below the waist and on both sides of the body, in addition to axial skeletal pain
- Chronic widespread pain with sleep disturbance and fatigue
Diagnosis
- Fibromyalgia