A 35-Year-Old Woman With Fatigue and Joint Pain

Zain Ul Abideen Asad, MD, MBBS


May 09, 2017

Physical Examination and Work-up

The patient has a body mass index of 33 kg/m2 (Figure 1). Her vital signs are within normal limits. No edema, hair loss, or skin changes are noted. She has pain on passive movements of joints but no deformities, swelling, or erythema. Her neck circumference is 16 inches, without evidence of thyroid enlargement or jugular venous distention. No vision changes are reported. All cranial nerves are grossly intact, and reflexes are 2+ throughout. Muscle strength is 4/5 in the upper and lower extremities. Her gait and range of motion for all extremities is normal.

The patient's complete blood count (CBC), basic metabolic panel, and urinalysis are unremarkable. Other findings are as follows:

  • Erythrocyte sedimentation rate (ESR): 15 mm/h (normal range, 0-20 mm/h);

  • C-reactive protein (CRP) - 0.6 mg/dL (normal range, 0.1-1 mg/dL);

  • Thyroid-stimulating hormone level: 4 µU/mL (normal range, 0.5-5.0 µU/mL);

  • Free T4: Within the normal range;

  • Creatine kinase level: within the normal range; and

  • Antinuclear antibody (ANA) titer: 1:160 (low-positive range, 1:40-1:60).

Although statin myopathy was considered, it typically presents as proximal muscle weakness. The patient here described muscle stiffness, and the creatine kinase level was normal. The patient is up to date on immunizations and Pap smear. Enzyme-linked immunoassays for HIV and Lyme disease and tests for viral hepatitis are negative. Sleep disorders are ruled out because they do not typically cause joint pain.


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