46-year-old woman with diffuse pain and normal labs
A 46-year-old woman comes to clinic for 9 months of diffuse musculoskeletal pain, unrefreshing sleep, and daytime fatigue. She has trouble concentrating at work and says even light pressure from clothing can feel uncomfortable. She has migraine and irritable bowel syndrome, but no fever, weight loss, joint swelling, weakness, or rash. Temperature is 36.8 C, blood pressure 124/76 mm Hg, and pulse 72/min. Examination shows diffuse soft-tissue tenderness without synovitis; strength and neurologic exam are normal. CBC, creatinine, TSH, ESR, and CK are normal. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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B
Explanation
Clinical Pearl:
Fibromyalgia is a clinical diagnosis characterized by chronic widespread pain, fatigue, poor sleep, and cognitive symptoms with a normal routine inflammatory and muscle workup. First-line treatment emphasizes education, graded exercise, and other nonpharmacologic strategies, with medications used selectively for persistent symptoms.
Explanation:
This patient has classic fibromyalgia, with chronic widespread pain, fatigue, sleep disturbance, cognitive complaints, and heightened pain sensitivity in the setting of a normal examination aside from diffuse tenderness and normal screening studies. Current practice favors nonpharmacologic treatment first, especially graded aerobic exercise and cognitive behavioral therapy, because these improve function and symptoms without the harms of unnecessary medication. Prednisone is not appropriate because there is no evidence of inflammatory arthritis, myositis, or another steroid-responsive condition. Antinuclear antibody and rheumatoid factor testing would add little here and can produce misleading false-positive results in a patient whose history, examination, and basic studies do not suggest connective tissue disease. Electromyography and muscle biopsy are reserved for suspected neuromuscular disease, which is not supported by her normal strength, normal CK, and lack of focal deficits. Long-term opioids are discouraged in fibromyalgia because they have poor evidence for benefit and carry substantial risks, including dependence and worse functional outcomes.
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