MKSAP Quiz: Evaluation for stiffness and pain
A 43-year-old man is evaluated for knee, hip, shoulder, and arm stiffness, worsening over the past year. He also has pain in the arms, legs, neck, and torso, both on and between the joints. He states that his discomfort is continuous. After a physical exam and lab studies, what is the most likely diagnosis?
A 43-year-old man is evaluated for knee, hip, shoulder, and arm stiffness, worsening over the past year. He also has pain in the arms, legs, neck, and torso, both on and between the joints. He states that his discomfort is continuous. He also reports chronic fatigue, lack of sleep, a band-like headache, and difficulty concentrating. He also has intermittent constipation and diarrhea. He takes acetaminophen and ibuprofen as needed for pain without much benefit.
On physical examination, the patient appears tired and anxious, with no acute distress. Vital signs are normal. He has minimal tenderness on palpation of multiple muscle groups. Full range of motion of all joints without crepitus is noted. There is no joint swelling or rash.
Laboratory studies, including complete blood count, erythrocyte sedimentation rate, serum creatine kinase, and thyroid-stimulating hormone, are within normal limits.
Which of the following is the most likely diagnosis?
A. Fibromyalgia
B. Hypothyroidism
C. Osteoarthritis
D. Rheumatoid arthritis
MKSAP Answer and Critique
The correct answer is A. Fibromyalgia. This content is available to MKSAP 18 subscribers as Question 69 in the Rheumatology section. More information about MKSAP is available online.
The most likely diagnosis is fibromyalgia. The characteristic features of fibromyalgia are widespread chronic pain, fatigue, and/or sleep disorders, which are frequently accompanied by impaired cognitive function, mood disorders, and symptoms such as headache, gastrointestinal symptoms, and paresthesia. Although this patient initially appears to have specific joint symptoms, he is actually experiencing widespread (including nonarticular) pain. This widespread pain, together with poor/nonrestorative sleep, fatigue, and cognitive dysfunction (in this case, difficulty concentrating), is consistent with fibromyalgia. The absence of tender points is not relevant; men with fibromyalgia frequently do not experience tender points, and tender points are no longer included in fibromyalgia classification criteria. Other features experienced by patients (bowel symptoms, anxiety/depression, low-grade fever, low-titer/borderline antinuclear antibodies) are not diagnostic of fibromyalgia but are consistent with its presence.
The clinical manifestations of hypothyroidism include fatigue, cold intolerance, constipation, weight gain, impaired concentration, dry skin, edema, depression, mood changes, muscle cramps, and myalgia. A normal thyroid-stimulating hormone level excludes hypothyroidism.
This patient's physical examination demonstrates full range of motion of the joints without crepitus, making osteoarthritis less likely. Additionally, osteoarthritis cannot explain his diffuse body pain, difficulty sleeping, chronic fatigue, bowel symptoms, headache, and difficulty concentrating.
Rheumatoid arthritis (RA) is characterized by pain and swelling in multiple (>3) small joints of the hands and/or feet, along with morning stiffness lasting at least 1 hour. Initial symptoms often worsen gradually over weeks to months. RA frequently interferes with activities of daily living, including occupational and recreational activities. Constitutional symptoms such as increased fatigue and malaise are common. Depression and myalgia may occur and, less often, fever, anorexia, and weight loss. Physical examination reveals tenderness and swelling of the joints, sometimes with warmth and erythema; symmetric joint involvement is common. This patient lacks the synovitis characteristic of RA.
Key Point
- The characteristic features of fibromyalgia are widespread chronic pain, fatigue, and sleep disorders, which are frequently accompanied by impaired cognitive function, mood disorders, and symptoms such as headache, gastrointestinal symptoms, and paresthesia.