A 29-Year-Old Woman With Worsening Pain and Memory Issues

Caroline Tschibelu, MD


May 08, 2019

Physical Examination and Workup

On physical exam, the patient is found to be a thin, tall woman in no acute distress. Her vital signs are within normal limits. Her cranial nerves are grossly intact, and her pupils are 3 mm, equal, and reactive bilaterally. Her reflexes are 2+ throughout. No Romberg sign or pronator drift is noted. Her strength is 4/5 in the upper extremities and 5/5 in the lower extremities. Her gait and range of motion for all extremities are normal. No deformities, swelling, or erythema over the joints are observed.

The examination findings are remarkable for extreme tenderness to palpation when pressure is applied over multiple areas of the body, including the occiput; the fourth through sixth intertransverse spaces of the cervical spine; bilaterally down the scapular, supraspinatus and trapezius muscles; and bilaterally on the medial aspect of both knees.

Her PCP performs a workup before referral. The patient's complete blood count (CBC), basic metabolic panel (BMP), and urinalysis (UA) are unremarkable. Her erythrocyte sedimentation rate (ESR) is 26 mm/h (reference range = 0-20 mm/h). Her C-reactive protein (CRP) level is 0.5 mg/dL (reference range = 0.0-0.8 mg/dL). Her thyroid stimulating hormone (TSH) level is 4 µU/mL (reference range = 0.5-5.0 µU/mL). Her free thyroxine (FT4) and free triiodothyronine (FT3) levels are within normal limits. Her creatine kinase level is within the reference range. Her antinuclear antibody (ANA) titer is 1:160 (low-positive range = 1:40 to 1:60). Her rheumatoid factor (RF) test result is positive.