“I’m just a bucket of problems.” The case of Raynelle C.
Chief Complaint: Aching pains of the neck, shoulders, chest, hips, and knees
Clinical History: Raynelle C. was a 43-year-old woman, a carpenter and Colorado mountain fishing guide in the summer, and a ski resort real estate saleswoman in the winter. During a lunch break while guiding her personal physician on a day of fly-fishing, she began asking questions about the pains she had been having. She related that, since the previous summer, she had been having aching pains in the back of her neck, in her upper chest and shoulders, and around her hips and knees. The pain was not related to activity and was not relieved by rest. “I hurt all the time,” she said. In response to questions, she reported numbness and increased sensitivity to touch in her extremities and added that her hands felt stiff each morning until she loosened them up, but said she had not had any weight loss, nor did she have fever or swollen joints. She confessed that she worried a lot about her husband’s real estate business and their personal finances, and was not sleeping well. She also complained of being tired all the time. “Well,” the physician said, “this is not something we can solve on a fishing trip. Call the office tomorrow and we’ll get to the bottom of this.” They finished the trip uneventfully. The physician saw Raynelle later in the week. “I’m tired all the time,” she sighed. “No wonder; I’m not sleeping very well. Sometimes I feel stiff as a zombie and I’m sore all over. I feel blue most of the time and sometimes I just don’t want to get out of bed. I’m irritable, too. I seem to fly off the handle with my husband at the smallest things. I’m just a bucket of problems,” she said. Further questioning revealed no history of recent illness. Systems review was unremarkable. Family history revealed that her parents, aunts, uncles, and two adult children were alive and healthy. There was no history of RA, headache, or insect bites. Her grandparents on both sides lived into their 80s and 90s. She did not know how they died.
Physical Examination and Other Data: Vital signs and blood pressure were unremarkable. She was of average height and a very fit, lean woman who appeared her stated age. No lymphadenopathy was present. Her skin showed no rash or hemorrhage. Her muscle strength was normal. There were no enlarged lymph nodes, rashes, joint abnormalities, or masses. Neurological exam was normal. Her temporal artery was not painful or nodular. Despite complaining of stiff hands and other joints, her joints were normally flexible and motion caused no pain. The most outstanding abnormality was tenderness to touch, sometimes to the point of jumpiness, in the muscles and tendons at the base of her skull and neck, shoulders, low paraspinal muscles, and around her knees and elbows. Her joints were not swollen or tender to manipulation. Upper arm, buttocks, thighs, and calf muscles were not tender to a firm squeeze. Laboratory tests were ordered and included CBC, blood chemistries, RF, ANA, CRP, CK, hepatitis C antibody, thyroid hormones, Lyme disease antibody, and ESR.
She was referred for X-rays of her hands and spine.
Clinical Course: She returned two weeks later for follow-up. X-rays and all laboratory tests were normal. The physician concluded she probably had fibromyalgia and prescribed a short, low dose course of steroids as a diagnostic test. Her failure to improve confirmed the diagnosis. The physician outlined a program of regular gym visits for moderate exercise and stretching; NSAIDs, heat and massage for pain; and antidepressants and sedatives to improve sleep. She responded fairly well. Pain lessened but did not disappear and she continued to work. Her mood and sleep improved, and she became less “jumpy” on physical examination.